MEDXXI 2010

Description of Service / Treatment

Services rendered as part of hospitalisation - subject to pre-authorisation:

 

OVERALL MAXIMUM

None

To be self-funded

HOSPITALISATION

Accommodation, theatre, medicine and material used whilst hospitalised

100% of Agreed Tariff

Not applicable

Outpatient treatment at hospital facility

Not applicable

To be self-funded

Medicine received on discharge from hospital

100% of Agreed Tariff (GRP applies), if purchased on date of discharge

MEDICAL PRACTITONERS

Consultations (Visits)

100% of Medical Scheme Rate – unlimited

To be self-funded

Radiology

100% of Medical Scheme Rate – unlimited

To be self-funded

ECHO-tests

100% of Medical Scheme Rate - unlimited

To be self-funded

MRI- and CT-scans and radio-isotope studies (Benefits subject to separate pre-authorisation)

100% of Medical Scheme Rate - R1 500 co-payment applies

100% of Medical SchemeRate.
R1 500 co-payment applies

Pathology

100% of Medical Scheme Rate - unlimited

To be self-funded

Clinical Procedures

100% of Medical Scheme Rate – unlimited

Co-payments applicable to certain elective procedures, unless funded as PMB treatment

Please refer to Members’ Guide for details

No benefits for:

- Joint replacements

- Spinal surgery

- Diagnostic laparoscopy, hysteroscopy or endometrial ablation

100% of Medical Scheme Rate for the following:
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 = To be self-funded

Material and injection material administered in doctor’s rooms

Not applicable

To be self-funded

MATERNITY

Foetal scans

100% of Medical Scheme Rate - unlimited

To be self-funded

Ante-natal classes

Not applicable

100% of cost limited to R1 000 per family per year

Confinement

Benefits as described in respect of Hospitalisation and Medical Practitioners

AUXILIARY SERVICES

Physiotherapy

100% of Medical Scheme Rate - unlimited

To be self-funded

Medical Technology

100% of Medical Scheme Rate - unlimited

To be self-funded

Clinical Technology

100% of Medical Scheme Rate - unlimited

To be self-funded

Speech Therapy and Occupational Therapy

100% of Medical Scheme Rate - unlimited

To be self-funded

Podiatry, orthoptic treatment, hearing aid acoustics, consultations with dietitians,

chiropractors, osteopaths, homeopaths, naturopaths, herbalists and biokinetics

To be self-funded

To be self-funded

Aromatherapy, acupuncture and reflexology

To be self-funded

To be self-funded

OPTICAL

Consultation

Not applicable

To be self-funded

Spectacles and Contact Lenses

Not applicable

To be self-funded

Refractive Surgery

To be self-funded

SECONDARY FACILITIES

Treatment that forms part of a Case Management Programme

100% of cost, subject to approval by case manager

100% of cost, subject to approval by case manager

REHABILITATION

To be self-funded, except for cases managed as part of a Case Management Programme, where a medical report was submitted by the attending physician

AMBULANCE SERVICES

Preferred Provider (ER24)

Not applicable

100% of Agreed Tariff for emergency transport to and from a hospital

Non-preferred Provider

Not applicable

100% of Medical Scheme Rate, limited to R1 600 per family per year

BLOOD TRANSFUSIONS

100% of cost

100% of cost

MEDICAL AND SURGICAL PROSTHESIS / APPLIANCES

Internal Prosthesis

Specific sub-categories with limits apply. Please refer to Members’ Guide for detail.

External Prosthesis

100% of cost, limited to R37 800 per family per year – subject to approval by case manager

OrthopaedicalAppliances

100% of cost limited to R5 400 per family per year, subject to case management

MedicalAppliances

Not applicable

To be self-funded

Hearing Aids

Not applicable

To be self-funded

DENTISTRY

Basic

To be self-funded

To be self-funded

Specialised

To be self-funded

MAXILLO-FACIAL AND ORAL SURGERY

Elective

To be self-funded

To be self-funded

Non-elective (excluding extractions)

100% of Medical Scheme Rate - R1 000 co-payment applies

100% of Medical Scheme Rate - unlimited

Implantology

To be self-funded

To be self-funded

PRESCRIBED MEDICINE

Chronic (member must apply for benefit)

Not applicable

To be self-funded except PMB

Acute

Not applicable

To be self-funded

Immunisations

Not applicable

To be self-funded

Oral contraceptives and IUD's

Not applicable

To be self-funded

NON-PRESCRIBED MEDICINE (PAT)

Not applicable

To be self-funded

CASE MANAGED / DISEASE MANAGED CONDITIONS / PROCEDURES

Organ Transplants

The following benefit apply to organ donors in RSA: R30 000 for a live donor, R18 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 transplant procedure also qualify for benefit

Chronic Renal Failure

100% of Medical Scheme Rate for kidney dialysis, including associated radiology and pathology tests - unlimited

Oncology

Benefit managed as part of an Oncology Benefit Management Programme and subject to use of Preferred Provider network. Overall limit of R160 000 per family per year. No benefits for biological drugs. Please refer to Members’ Guide for more detail.

Asthma, Chronic Obstructive Airways Disease, Diabetes and Cardiocare

Benefit managed by Scheme and payable as per the applicable benefit described elsewhere in this summary.

Oxygen therapy

100% of cost of oxygen therapy (cylinders included) subject to Case Management

AIDS and HIV

Benefits managed as part of a Disease Management programme.

FOREIGN CLAIMS

No benefits except for Namibian claims.

MENTAL HEALTH

Clinical Psychology

100% of Medical Scheme Rate – unlimited. Treatment must form part of Case Management Programme

To be self-funded

Psychiatry

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.

PRESCRIBED MINIMUM BENEFIT

Benefits subject to application and provided that the treatment and/or chronic medicine is received from a public healthcare facility, Clicks Direct Medicines or Chronicare courier Pharmacy. If voluntarily obtained from any other provider, a co-payment (determined by the Scheme) will apply. Scheme protocol apply.