SelfNET Essential 2018

Below is a summary of the benefits and contributions. In case of dispute, the registered scheme rules apply.

*Services rendered as part of hospitalisation are subject to pre-authorisation.

Description of Service/ Treatment Services rendered as part of hospitalisation* Services rendered NOT as part of hospitalisation
HOSPITALISATION
Accommodation, theatre, medicine and material used whilst hospitalised 100% of Negotiated Tariff at Scheme’s DSP, limited to PMB Not Applicable
Outpatient treatment at hospital facility Not Applicable To be self funded
Medicine received on discharge from hospital 100% of Network Rate (RP applies), if purchased on date of discharge, limited to a maximum of 7 days supply
MEDICAL PRACTITIONERS
General Consultations / Visits 100% of Network Rate – Unlimited – Subject to PMB treatment and protocol To be self funded
Specialist Practitioners Consultations / Visits 100% of Network Rate – Unlimited – Subject to PMB treatment and protocol To be self funded
Basic Radiology 100% of Network Rate – Unlimited – Subject to PMB treatment and protocol To be self funded
MRI- and CT-scans and radio-isotope studies (Benefits subject to seperate pre-authorisation) 100% of the Network Rate for MRI-, CT scans, performed in or out of hospital, subject to PMB regulation, obtaining a PAR, motivation and approval
Basic Pathology 100% of Network Rate – Unlimited – Subject to PMB treatment and protocol No benefit unless treatment forms part of PMB treatment and protocol
Clinical Procedures 100% of Network Rate – Unlimited – Subject to PMB treatment and protocol No benefits will be allowed for elective Clinical Procedures, unless treatment forms part of PMB protocol
Material and injection material administered in doctor’s rooms Not Applicable To be self funded
MATERNITY
Confinement Subject to pre-authorisation and Network Provider referral process Not Applicable
AUXILIARY SERVICES
Physiotherapy 100% of Network Rate – Unlimited – Subject to PMB treatment and protocol To be self funded
Medical Technology 100% of Network Rate – Unlimited – Subject to PMB treatment and protocol To be self funded
Clinical Technology 100% of Network Rate – Unlimited – Subject to PMB treatment and protocol To be self funded
Speech Therapy and Occupational Therapy 100% of Network Rate – Unlimited – Subject to PMB treatment and protocol 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 Relexology 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 To be self funded
SECONDARY FACILITIES
Treatment that forms part of a Case Management Programme 100% of Cost – Subject to approval by Case Manager and PMB regulation
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. PMB regulation will apply.
AMBULANCE SERVICES
Preferred Provider (ER24) Not Applicable 100% of Newtork Rate – For emergency transport to and from a hospital
Non-preferred Provider Not Applicable To be self funded
BLOOD TRANSFUSIONS
Blood transfusions 100% of Cost, Subject to pre-authorisation – Limited to PMB To be self funded
MEDICAL AND SURGICAL PROSTHESIS / APPLIANCES (CASE MANAGED)
Internal Prosthesis Funded as PMB treatment only
External Prosthesis Funded as PMB treatment only
Orthopaedic Applicances Funded as PMB treatment only
Medical Appliances Funded as PMB treatment only
Hearing Aids Not Applicable To be self funded
DENTISTRY
Basic To be self funded To be self funded
Specialised To be self funded To be self funded
MAXILLA-FACIAL AND ORAL SURGERY
Elective To be self funded To be self funded
Non-elective 100% of Cost – Limited to PMB and subject to pre-autorisation and Network Clinical Protocol To be self funded
Implantology To be self funded To be self funded
PRESCRIBED MEDICINE
Chronic (Member must apply for benefit) Not Applicable Benefit is subject to approval and in accordance with the CDL Chronic Medicine Formulary. Medication to be supplied by Network Provider.
Acute Not Applicable To be self funded
Immunisations Not Applicable To be self funded
NON-PRESCRIBED MEDICINE(PAT)
Non-Prescribed Medicine (PAT) Not Applicable To be self funded
CASE MANAGED / DISEASE MANAGED CONDITIONS / PROCEDURES
Organ Transplants Benefits will only be allowed in respect of heart-, lung-, heart- and lung-, bone-marrow, kidney- and liver transplants. Benefits will apply in respect of a donor, provided that the donor is in RSA and further subject to the recipient being a beneficiary of the Scheme. Specific Radiology and Pathology tests associated with transplant procedure also qualify for benefit
Chronic Renal Failure 100% of Network Rate for Kidney Dialysis, including associated Radiology and Pathology tests – subject to PMB protocol
Oncology Benefits are payable for PMB only. Benefit managed as part of a Disease Management Programme and use of the Scheme’s DSP network. No benefit for Biological drugs
Asthma, Chronic Obstructive Airways Disease, Diabetes and Cardiocare Benefit managed by the Scheme and payable as per the applicable benefit described elsewhere in this summary
Oxygen Therapy 100% of Network Rate of Oxygen therapy (cylinders included) subject to Case Management
AIDS AND HIVS – Benefits management as part of a Disease Management Programme
FOREIGN CLAIMS – No benefit, except for Namibian claims
MENTAL HEALTH
Clinical Psychology & Psychiatry Benefits for treatment out of hospital are subject to pre-authorisation, Case management through treatment plan and subject to PMB regulation Benefits for treatment in hospital are subject to pre-authorisation, Case management through treatment plan and subject to PMB regulation
PRESCRIBED MINIMUM BENEFITS (PMB) – Benefits subject to application and provided that the treatment and/or chronic medicine is received from a Designated Service Provider. If voluntarily obtained from any other provider, a co-payment of 40% will apply. Scheme protocol apply.

 

CONTRIBUTIONS – EFFECTIVE 1 JANUARY 2018
Contributions Principal Member
R 915.00
Additional Adult Member
R 915.00
Additional Minor Dependant
(payable up to maximum of 3)
R 325.00
ABBREVIATIONS:

RP = Reference Pricing | PMB = Prescribed Minimum Benefits
This is only a summary of the Benefits and Contributions.In case of a dispute the Registered Scheme Rules apply. Reg. No: 1446