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MedXXI Comprehensive 2009
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Description of Service / Treatment |
Services rendered as part of hospitalisation subject to pre-authorisation:-
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Services rendered NOT as part of hospitalisation:
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Accommodation, theatre, medicine and material used whilst hospitalised
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Outpatient treatment at hospital facility
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Benefits as described in respect of doctor visits and acute medicine
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Medicine received on discharge from hospital
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100% of Agreed Tariff (MMAP applies), if purchased on date of discharge
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200% of Medical Scheme Rate - unlimited
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ATB: 100% of Medical Scheme Rate.
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200% of Medical Scheme Rate - unlimited
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ATB: 100% of Medical Scheme Rate
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200% of Medical Scheme Rate - unlimited
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ATB: 100% of Medical Scheme Rate, limited to R1 800 per beneficiary per year. Limit applies even before threshold is reached.
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MRI- and CT-scans and radio-isotope studies
(Benefits subject to separate pre-authorisation)
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200% of Medical Scheme Rate - R1 000 co-payment applies
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200% of Medical Scheme Rate -
R1 000 copayment applies
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200% of Medical Scheme Rate - unlimited
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ATB: 100% of Medical Scheme Rate
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200% of Medical Scheme Rate - unlimited.
Co-payments applicable to certain elective procedures unless funded as PMB treatment.
Refer to Members’ Guide for details.
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200% of Medical Scheme Rate for the following, subject to pre-authorisation:
Upper and lower gastro-intestinal endoscopy (excl. sigmoidoscopy and anoscopy)
Laser tonsillectomy
24-hour oesophageal pH studies
Oesophageal motility
Yag laser
Photocoagulation therapy
Photodynamic therapy
All other clinical procedures = ATB: 100% of Medical Scheme Rate
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Material and injection material administered in doctor's rooms
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ATB: 100% of Medical Scheme Rate
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200% of Medical Scheme Rate - unlimited
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ATB: 100% of Medical Scheme Rate
Benefits limited to 2 per beneficiary per year and the cost of a 3D-scan is
limited to the cost of a 2D-scan. Limit applies even before threshold is reached.
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100% of cost, limited to R1 000 per family per year
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Benefits as described in respect of Hospitalisation and Medical Practitioners
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200% of Medical Scheme Rate - unlimited
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ATB: 100% of Medical Scheme Rate
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200% of Medical Scheme Rate - unlimited
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ATB: 100% of Medical Scheme Rate
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200% of Medical Scheme Rate - unlimited
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ATB: 100% of Medical Scheme Rate – and jointly limited to
R3 600 per beneficiary to a maximum of R10 800 per family per year.
These limits apply only after threshold is reached.
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Occupational Therapy and Speech Therapy
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200% of Medical Scheme Rate - unlimited
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Podiatry, orthoptic treatment, hearing aid acoustics, consultations with dietitians,
chiropractors, osteopaths, homeopaths, naturopaths, herbalists and biokinetics
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Benefits as described in respect of services rendered not as part of hospitalisation
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Aromatherapy, acupuncture and reflexology
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ATB: 100% of Medical Scheme Rate.
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Spectacles and Contact Lenses
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ATB: 100% of Medical Scheme Rate, limited to R2 000 per beneficiary with a maximum of R5 700 per family per year, including a sub-limit of R870 per frame per beneficiary to a maximum of R2 400 per family per year.
(Limits applicable even before threshold is reached)
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Treatment that forms part of a Case Management Programme
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100% of cost, subject to approval by case manager
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100% of cost, subject to approval by case manager
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Only benefits for cases managed as part of a Case Management Programme, where a medical report was submitted by the attending physician.
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Preferred Provider (ER24)
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100% of Agreed Tariff for emergency transport to and from a hospital
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100% of Medical Scheme Rate, limited to R1 500 per family per year (not subject to threshold)
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MEDICAL AND SURGICAL PROSTHESIS / APPLIANCES
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Specific sub-categories with limits apply. Please refer to Members’ Guide for detail
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100% of cost, limited to R35 000 per family per year – subject to approval by case manager
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100% of cost limited to R5 000 per family per year, subject to case management
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ATB: 100% of cost, limited to R3 000 per family per year. This limit applies
only once threshold is reached.
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ATB: 100% of cost, limited to R10 800 per family per year. This limit applies
only once threshold is reached.
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100% of Medical Scheme Rate subject jointly to limit for specialised dentistry (R1 000 co-payment applies to procedures in hospital)
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80% of Medical Scheme Rate – limited to R5 800 per beneficiary to a maximum of R12 000 per family per year (R1 000 co-payment applies to procedures in hospital)
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MAXILLO-FACIAL AND ORAL SURGERY
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ATB: 80% of Medical Scheme Rate -R1 000 co-payment
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ATB: 80% of Medical Scheme Rate
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200% of Medical Scheme Rate - R1 000 co-payment
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200% of Medical Scheme Rate - unlimited
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ATB: 80% of Medical Scheme Rate. The cost of the implants (prosthesis) is limited to R3 600 per beneficiary and this limit applies even before threshold is reached. (R1 000 co-payment applies to procedures in hospital)
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Chronic (member must apply for benefit)
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Only Prescribed Minimum Benefits
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ATB: 100% of Agreed Tariff, limited to R3 600 per beneficiary to a maximum of R10 800 per family per year. These limits apply after threshold is reached.
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Oral contraceptives and IUD's
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NON-PRESCRIBED MEDICINE (PAT)
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CASE MANAGED / DISEASE MANAGED CONDITIONS / PROCEDURES
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The following benefit apply to organ donors in RSA: R28 000 for a live donor, R17 000 for a cadavre. Benefit in respect of donors only allowed if the recipient of the organ is a beneficiary of the Scheme. Specific radiology and pathology tests associated with the transplant procedure will also qualify for benefits
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200% of Medical Scheme Rate for kidney dialysis, including associated radiology and pathology services - unlimited
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Benefit managed as part of an Oncology Benefit Management Programme. Overall limit of R200 000 per family per year and sublimit (R100 000) for biological drugs, if approved by scheme. Please refer to Members’ Guide for more detail.
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Asthma, Chronic Obstructive Airways Disease, Diabetes and Cardiocare
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Benefit managed by Scheme and payable as per the applicable benefit described elsewhere in this summary.
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100% of cost of oxygen therapy (cylinders included) subject to Case Management
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100% of cost of oxygen therapy (cylinders included) subject to Case Management
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Benefits managed as part of a Disease Management Programme
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No benefits except for Namibian claims.
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200% of Medical Scheme Rate – unlimited. Treatment must form part of Case Management Programme
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ATB: 100% of Medical Scheme Rate – limited to R3 600 per family per year. This limit applies only after threshold is reached.
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Benefit as described elsewhere in this summary for Medical Practitioners and Hospitalisation. Treatment to be obtained in a mental health institution, as approved by the Scheme.
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Day-to-day claims paid from own pocket accumulate to specified thresholds (Rand value) which must be reached, prior to the Scheme paying for the services indicated above:
Single member = R9 500
Additional amount for every registered Adult Dependant = R5 500
Additional amount for every registered Minor Dependant = R1 700
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PRESCRIBED MINIMUM BENEFIT |
Benefits subject to application and provided that the treatment and/or chronic medicine is received from a public healthcare facility or Chronicare courier Pharmacy. If voluntarily obtained from any other provider, a co-payment (determined by the Scheme) will apply. See Members' Guide for more detail. Scheme protocol apply.
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