Selfmed Selfsure 2012

OVERALL MAXIMUM

None

Annual Day-to-day Limit:
Principal Member = R3 500
Additional per adult dependant = R2 500
Additional per minor dependant = R1 200 (to a maximum of R3 600)

Radiology, pathology, basic dentistry, physiotherapy and biokinetics = R3 600 or R5 000 for family
Optometry= 100% of cost limited to R1 900 per beneficiary or R3 800 per family over two years
Medical appliances = R3 200 per family

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 (RP applies), if purchased on date of discharge

MEDICAL PRACTITONERS

Consultations (Visits)

100% of Medical Scheme Rate - unlimited

100% of Medical Scheme Rate – subject to Annual Day-to-day Limit

Radiology and Pathology

100% of Medical Scheme Rate - unlimited

100% of Medical Scheme Rate

ECHO-tests

100% of Medical Scheme Rate - unlimited

100% 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 – R1 600 co-payment applies

100% of Medical Scheme Rate – R1 600 co-payment applies

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 detail
No benefits for elective procedures, unless funded as PMB treatment:
– Joint replacements
– Spinal surgery
– Diagnostic laparoscopy, hysteroscopy or endometrial ablation

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 = 100% Medical Scheme Rate subject to Annual Day-to-day Limit

Cochlear Implants

100% of Medical Scheme Rate, limited to R22 500 per implant

Not applicable

Material and injection material administered in doctor’s rooms

Not applicable

100% of cost – subject to Annual Day-to-day Limit

MATERNITY

Foetal scans

100% of Medical Scheme Rate – unlimited

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

Ante-natal Classes

100% of Medical Scheme Rate- unlimited

Ante-natal classes

Not applicable

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

Confinement

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

AUXILIARY SERVICES

Medical Technology

100% of Medical Scheme Rate - unlimited

100% of Medical Scheme Rate - subject to Annual Day-to-day Limit

Clinical Technology

100% of Medical Scheme Rate - unlimited

100% of Medical Scheme Rate - subject to Annual Day-to-day Limit

Physiotherapy and Biokinetics

100% of Medical Scheme Rate - unlimited

100% of Medical Scheme Rate - subject to joint limit for radiology, pathology and basic dentistry

Speech Therapy and Occupational Therapy

100% of Medical Scheme Rate – subject to Annual Day-to-day Limit

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

chiropractors, osteopaths, homeopaths, naturopaths and herbalists

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

Aromatherapy, acupuncture and reflexology

To be self-funded

OPTICAL

100% of cost limited to R1 900 per beneficiary or R3 800 per family over two years

Consultation

Not applicable

100% of cost

Spectacles and Contact Lenses

Not applicable

100% of cost

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 R2 000 per family per year

BLOOD TRANSFUSIONS

100% of cost

100% of cost

MEDICAL AND SURGICAL PROSTHESIS / APPLIANCES (CASE MANAGED)

Internal Prosthesis

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

External Prosthesis

100% of cost, limited to R42 000 per family per year – subject to approval by Case Manager

Orthopaedic Appliances

100% of cost limited to R6 000 per family per year, subject to Case Management

Medical Appliances

Not applicable

100% of cost, limited to R3 200 per family per year

Hearing Aids

Not applicable

To be self-funded

DENTISTRY

Basic

100% of Medical Scheme Rate – R1 100 co-payment applies and subject to joint limit for radiology, pathology, physiotherapy and biokinetics

100% of Medical Scheme Rate – subject to joint limit for radiology, pathology, physiotherapy and biokinetics

Specialised

100% of Medical Scheme Rate – R1 100 co-payment applies and subject to Annual Day-to-day Limit

100% of Medical Scheme Rate – subject to Annual Day-to-day Limit

MAXILLO-FACIAL AND ORAL SURGERY

Elective

100% of Medical Scheme Rate - R1 100 co-payment and subject to Annual Day-to-day Limit

100% of Medical Scheme Rate - subject to Annual Day-to-day Limit

Non-elective

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

100% of Medical Scheme Rate - unlimited

Implantology

100% of Medical Scheme Rate – R1 100 co-payment and subject to Annual Day-to-day Limit

100% of Medical Scheme Rate - subject to Annual Day-to-day Limit

PRESCRIBED MEDICINE

Chronic (member must apply for benefit)

Not applicable

No benefit, except PMB's

Acute

Not applicable

100% of Agreed Tariff (RP applies) – subject to Annual Day-to-day Limit

Immunisations

Not applicable

Oral contraceptives and IUD's

Not applicable

NON-PRESCRIBED MEDICINE (PAT)

Not applicable

100% of Agreed Tariff (RP applies) - limited to R190 per day and subject to Annual Day-to-day Limit

CASE MANAGED / DISEASE MANAGED CONDITIONS / PROCEDURES

Organ Transplants

The following benefits apply to organ donors in RSA: R33 500 for a live donor, R20 000 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

Subject to the Oncology Management Programme and further subject to the Scheme's preferred provider (ICON). Overall limit of R181 500 per family per year applies. No benefit for biological drugs.
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 benefit, except for Namibian claims

MENTAL HEALTH

Clinical Psychology

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

100% of Medical Scheme Rate – subject to Annual Day-to-day Limit

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. Please refer to Members' Guide for more detail. If voluntarily obtained from any other provider, a co-payment (determined by the Scheme) will apply. Scheme protocol apply