Selfmed 80% 2011

OVERALL MAXIMUM

None

None

HOSPITALISATION

Accommodation, theatre, medicine and material used whilst hospitalised

100% of Agreed Tariff

Not applicable

Outpatient treatment at hospital facility

Not applicable

Benefits as described in respect of doctor visits and acute medicine

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

80% of Medical Scheme Rate – subject to following limits:

Single member = max 15 visits

Member + 1 dependant = max 30 visits

Member + 2 or more dependants = max 45 visits

Radiology

100% of Medical Scheme Rate - unlimited

80% of Medical Scheme Rate - unlimited

ECHO-tests

100% of Medical Scheme Rate - unlimited

80% of Medical Scheme Rate - limited to R2 000 per beneficiary per year

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

100% of Medical Scheme Rate - unlimited - R1 100 co payment

80% of Medical Scheme Rate - R1 100 co payment

Pathology

100% of Medical Scheme Rate - unlimited

80% of Medical Scheme Rate - unlimited

Clinical Procedures

100% of Medical Scheme Rate - unlimited

100% 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 are payable at 80% of Medical Scheme Rate - unlimited

Cochlear implants

100% of Medical Scheme Rate, limited to R52 500 per implant

Not applicable

Material and injection material administered in doctor's rooms

Not applicable

80% of Medical Scheme Rate - unlimited

MATERNITY

Foetal scans

100% of Medical Scheme Rate - unlimited

80% of Medical Scheme Rate – unlimited Benefits further limited to 2 per beneficiary per year and the cost of a 3D-scan is limited to the cost of a 2D-scan

Ante-natal classes

To be self-funded

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

Confinement

Benefits as described in respect of Medical Practitioners and Hospitalisation

AUXILIARY SERVICES

Medical Technology

100% of Medical Scheme Rate – unlimited

80% of Medical Scheme Rate - unlimited

Clinical Technology

100% of Medical Scheme Rate - unlimited

80% of Medical Scheme Rate - unlimited

Physiotherapy

100% of Medical Scheme Rate - unlimited

80% of Medical Scheme Rate – limited to R3 200 per beneficiary to a maximum of R9 600 per family per year

Speech Therapy and Occupational Therapy

100% of Medical Scheme Rate – unlimited treatment to form part of a Case Management Programme)

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

chiropractors, osteopaths, homeopaths, naturopaths, herbalists and biokinetics

Benefits as described in respect of services rendered not as part of hospitalisation

Aromatherapy, acupuncture and reflexology

To be self-funded

OPTICAL

Consultation

Not applicable

80% of Medical Scheme Rate

Spectacles and Contact Lenses

Not applicable

80% of Medical Scheme Rate, limited to R1 400 per beneficiary to a maximum of R4 000 per family per year

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

Only benefits 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 700 per family per year

BLOOD TRANSFUSIONS

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 R39 700 per family per year – subject to approval by case manager

Orthopaedic Appliances

100% of cost limited to R5 700 per family per year, subject to case management

Medical Appliances

Not applicable

80% of cost, limited to R2 500 per family per year

Not applicable

80% of cost, limited to R9 900 per family per year

DENTISTRY

Basic

80% of Medical Scheme Rate

Specialised

80% of Medical Scheme Rate – limited to R5 300 per beneficiary to a maximum of R1 600 per family per year

MAXILLO-FACIAL AND ORAL SURGERY

Elective

80% of Medical Scheme Rate - unlimited

Non-elective

100% of Medical Scheme Rate - unlimited

Implantology

80% of Medical Scheme Rate – implants (prosthesis) limited to R4 000 per beneficiary per year

PRESCRIBED MEDICINE

Chronic (member must apply for benefit)

Not applicable

80% of Agreed Tariff (GRP applies), limited to R16 000 per beneficiary per year with a maximum of R31 000 per family per year

Acute

Not applicable

80% of Agreed Tariff (GRP applies) - limited to R4 000 per beneficiary to a maximum of R11 900 per family per year

Immunisations

Not applicable

Oral contraceptives and IUD's

Not applicable

NON-PRESCRIBED MEDICINE (PAT)

Not applicable

80% of Agreed Tariff (GRP applies) - limited to R930 per family per year and subject to the acute medicine maximum

CASE MANAGED / DISEASE MANAGED CONDITIONS / PROCEDURES

Organ Transplants

The following benefits apply to organ donors in RSA: R31 500 for a live donor, R18 900 for a cadavre. Benefits 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

Chronic Renal Failure

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

Oncology

Benefits managed as part of an Oncology Management Programme. Overall limit of R288 900 per family per year applies with a sub-limit of R115 600 for biological drugs, if approved by scheme. Please refer to Members' Guide for more detail.

Asthma, Chronic Obstructive Airways Disease, Diabetes and Cardiocare

Benefits managed by Scheme and payable as per the applicable benefits 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 – provided that treatment must form part of Case Management Programme

80% of Medical Scheme Rate – limited to R6 000 per family per year

Psychiatry

Benefits 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 BENEFITS

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 (determined by the Scheme) will apply. Scheme protocol apply