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Selfmed Selfsure 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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Annual Day-to-day Limit:
Principal Member = R3 400
Additional per adult dependant =
R2 100
Additional per minor dependant =
R1 100 (to a maximum of R3 300)
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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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100% of Medical
Scheme Rate - unlimited
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100% of Medical Scheme Rate – subject to Annual Day-to-day Limit
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100% of Medical
Scheme Rate - unlimited
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100% of Medical Scheme Rate – jointly limited to R2 800 per family per year (basic dentistry, physiotherapy and biokinetics are part of this limit)
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100% of Medical
Scheme Rate - unlimited
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100% of Medical Scheme Rate – limited to R1 800 per beneficiary per year
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MRI- and CT-scans and radio-isotope
studies (Benefits subject to separate pre-authorisation)
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100% of Medical
Scheme Rate - R1000 co-payment applies
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100% of Medical Scheme Rate –
R1 000 co-payment applies
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100% of Medical Scheme Rate – unlimited
Co-payments applicable to certain elective procedures, unless funded as PMB treatment.
Please refer to Member’s Guide for detail.
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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 = 100% Medical Scheme Rate subject to Annual
Day-to-day Limit
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Material and injection material
administered in doctor’s rooms
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100% of cost – subject
to Annual Day-to-day Limit
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100% of Medical
Scheme Rate – unlimited
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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
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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. Benefits in respect of babies weighing less than 1 kilogram at birth, are limited to the Prescribed Minimum Benefits.
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100% of Medical
Scheme Rate - unlimited
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100% of Medical Scheme
Rate - subject to Annual Day-to-day Limit
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100% of Medical
Scheme Rate - unlimited
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100% of Medical Scheme
Rate - subject to Annual Day-to-day Limit
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Physiotherapy and Biokinetics
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100% of Medical
Scheme Rate - unlimited
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100% of Medical Scheme Rate - subject to joint limit for radiology, pathology and basic dentistry
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Speech Therapy and Occupational
Therapy
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100% of Medical
Scheme Rate – unlimited (treatment to form part of
a Case Management Programme)
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100% of Medical
Scheme Rate – subject to Annual Day-to-day Limit
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Podiatry, orthoptic treatment,
hearing aid acoustics, consultations with dietitians,
chiropractors, osteopaths, homeopaths, naturopaths and herbalists
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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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100% of cost - subject
to Annual Day-to-day Limit
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Spectacles and Contact Lenses
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100% of cost - limited
to R1 400 per beneficiary per year and subject to Annual
Day-to-day Limit
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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
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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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100% of cost, limited to R2 800 per family per year
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100% of cost, limited to R5 400 per family per year
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100% of Medical Scheme Rate - R1 000 co-payment and subject to joint limit for radiology, pathology, physiotherapy and biokinetics
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100% of Medical Scheme Rate - subject to joint limit for radiology, pathology, physiotherapy and biokinetics
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100% of Medical Scheme Rate - R1 000 co-payment and subject to Annual Day-to-day Limit
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100% of Medical Scheme Rate - subject to Annual Day-to-day Limit
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MAXILLO-FACIAL
AND ORAL SURGERY
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100% of Medical Scheme Rate - R1 000 co-payment and subject to Annual Day-to-day Limit
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100% of Medical Scheme Rate - subject to Annual Day-to-day Limit
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100% of Medical Scheme Rate - R1 000 co-payment
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100% of Medical Scheme
Rate - unlimited
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100% of Medical Scheme Rate – R1 000 co-payment and subject to Annual Day-to-day Limit
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100% of Medical Scheme Rate - subject to Annual Day-to-day Limit
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Chronic (member must apply
for benefit)
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100% of Agreed Tariff (reference price applies), limited to R3 300 per beneficiary per year
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100% of Agreed Tariff (MMAP applies) – subject to Annual Day-to-day Limit
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Oral contraceptives and IUD's
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NON-PRESCRIBED
MEDICINE (PAT)
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100% of Agreed Tariff (MMAP applies) - limited to R160 per day and subject to Annual Day-to-day Limit
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CASE
MANAGED / DISEASE MANAGED CONDITIONS / PROCEDURES
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The following benefits apply to organ donors in RSA: R28 000 for a live donor, R17 000 for a cadavre. Benefits in respect of donors only allowed if the recipient of the organ is a beneficiary of the Scheme.
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100% of Medical Scheme Rate for kidney dialysis, including associated radiology and pathology services - unlimited
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100% of Medical Scheme Rate - unlimited
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Benefits managed as part of an Oncology Management Programme. Overall limit of R100 000 per family per year applies. No benefit for biological drugs. Please refer to Members’ Guide for more detail.
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Asthma, Chronic Obstructive Airways Disease, Diabetes and Cardiocare
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Benefits managed by Scheme and payable as per the applicable benefits 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 benefit, except for Namibian claims
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100% of Medical Scheme Rate – unlimited. Treatment must form part of Case Management Programme
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100% of Medical Scheme Rate – subject to Annual Day-to-day Limit
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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.
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PRESCRIBED MINIMUM BENEFITS |
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. Scheme protocol apply. |
