Selfmed 80% 2018

Available with all our options
  • Unlimited hospitalisation at any of the Scheme’s Designated Hospitals
  • Medicine on discharge payable from hospital benefit
  • Unlimited emergency transport benefits where the services of ER24 is utilised in South Africa, Swaziland and Lesotho
  • Access to professional, specialised disease management programmes when diagnosed with a life-threatening condition, e.g. cancer or HIV/AIDS
  • MRI- and CT-scans payable from major medical benefits, both during and/or not during hospitalisation
  • Unlimited benefits for laser tonsillectomies, gastroscopies and colonoscopies when performed both during and/or not during hospitalisation (co-payments
    may apply)
  • Generous benefits for pregnancy and birth, including home deliveries by a – registered midwife
  • Unlimited benefits for rehabilitation and home nursing, subject to scheme approval.
  • * the above differ from option to option, and may be subject to approval or co-payment; benefits do not apply to SelfNET option

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 – subject to pre-authorisation Services rendered NOT as part of hospitalisation
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, subject to a maximum of 7 days supply
MEDICAL PRACTITIONERS
Consultations/ Visits 80% of Cost  or 100% of Medical Scheme Rate, whichever is greater – Unlimited 80% of Cost – subject to the following limits:

Single member = max 15 visits
Member + 1 dependant = max 30 visits
Member + 2 or more dependants = max 45 visits

Radiology and Pathology 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 R 3,000.00 per beneficiary per year

MRI- and CT-scans and radio-isotope studies (Benefits subject to seperate pre-authorisation) 100% of Medical Scheme Rate – R1,100.00 co-payment applies 80% of Medical Scheme Rate R 1,100.00 co-payment applies
Clinical Procedures 80% of Cost  or 100% of Medical Scheme Rate, whichever is greater – Unlimited 80% of cost 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 Cost – Unlimited

Cochlear Implants 100% of Medical Scheme Rate – limited to R 74,500.00 per implant Not Applicable
Material and injection material administered in doctor’s rooms Not Applicable 80% of Agreed Tariff (RP applies) – Subject to Acute Medicine Limit
MATERNITY
Ante-natal Classes and Foetal Scans 100% of Medical Scheme Rate – Unlimited 80% of Cost – Benefits limited to 2 per beneficiary per year and the cost of a 3D-scan is limited to the cost of a 2D-scan, payable at 80% of Cost. Benefits allowed for additional pregnancy scans and/or prechildbirth education at 100% of Cost to a maximum of R 1,700.00 per Family per Year
Confinement 100% of Agreed Tariff in respect to hospitalisation and 80% of Cost or 100% of Medical Scheme Rate in respect of Associated Provider Services – Unlimited
AUXILIARY SERVICES  – Combined sub-limit may apply
Clinical Technology 100% of Medical Scheme Rate – Unlimited 80% of Medical Scheme Rate – Unlimited
Medical Technology 100% of Medical Scheme Rate – Unlimited 80% of Medical Scheme Rate – Unlimited
Physiotherapy & Biokinetics 100% of Medical Scheme Rate – Unlimited 80% of Medical Scheme Rate – Limited to R5,100 per beneficiary to a maximum of R14,300 per family per year
Speech Therapy and Occupational Therapy 100% of Medical Scheme Rate – Unlimited Treatment to form part of a Case Management Programme 80% of Medical Scheme Rate – Limited to R5,100 per beneficiary to a maximum of R14,300 per family per year
Podiatry, Orthoptic treatment, Hearing Aid Acoustics, consultations with Dietitians, Chiropractors, Osteopaths, Homeopaths, Naturopaths and Herbalists 100% of Medical Scheme Rate – Benefits as described in respect of services rendered not as part of hospitalisation 80% of Medical Scheme Rate – Limited to R5,100 per beneficiary to a maximum of R14,300 per family per year.
Aromatherapy, Acupuncture and Relexology To be self funded To be self funded
OPTICAL
Consultation Not Applicable 80% of Scheme Tariff for a standard eye examinaton per beneficiary per 24 month period – Subject to combined family limit per 24 month cycle
Spectacles and Contact Lenses Not Applicable 80% of Scheme Tariff for a pair of generic standard lenses – 100% of Cost for a frame limited to R1,400 per beneficiary per 24 month period – OR – 80% of Scheme Tariff  for clear contact lenses limited to R1,800 per beneficiary per 24 month period – Subject to combined family limit per 24 month cycle
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
REHABILITATION – Only 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 hospital
Non-preferred Provider Not Applicable 100% of Medical Scheme Rate. Limited to R 2,800.00 per family per year. Limit will not apply to PMB
BLOOD TRANSFUSIONS
Blood transfusions 100% of Cost – Subject to pre-authorisation
MEDICAL AND SURGICAL PROSTHESIS / APPLIANCES (CASE MANAGED)
Internal Prosthesis 100% of Cost. Specific sub-categories with limits apply. Please refer to Member Guide for detail
External Prosthesis 100% of Cost -Limited to R 63,700.00 per family per year – Subject to approval by Case Manager
Orthopaedic Applicances 100% of Cost, limited to R 9,400.00 per family per year – Subject to Case Management
Medical Appliances Not Applicable 80% of Cost – limited to R 5,300.00 per family per year. This maximum may be exceeded, subject to a maximum limit of R 15,900.00, in respect of certain appliances, provided that the treatment forms part of a Case Management Programme
Hearing Aids Not Applicable 80% of Cost – Limited to R16,200.00 per family per year
DENTISTRY
Basic 80% of Medical Scheme Rate – Unlimited 80% of Medical Scheme Rate – Unlimited
Specialised 80% of Medical Scheme Rate – limited to R 8,100.00 per beneficiary to a maximum of R 24,900.00 per family per year
MAXILLA-FACIAL AND ORAL SURGERY
Elective 80% of Medical Scheme Rate – Unlimited 80% of Medical Scheme Rate – Unlimited
Non-elective (excluding extractions) 100% of Medical Scheme Rate – Unlimited. In the event of PMB, 100% of Cost, Subject to PMB protocol 100% of Medical Scheme Rate – Unlimited. In the event of PMB, 100% of Cost, Subject to PMB protocol
Implantology 80% of Medical Scheme Rate – implants (prosthesis) limited to R 5,600.00 per beneficiary per year
PRESCRIBED MEDICINE
Chronic (Member must apply for benefit) Not Applicable 80% of Agreed Tariff (RP applies), limited to R 24,600.00 per beneficiary per year with a maximum of R 47,900.00 per family per year
Acute Not Applicable 80% of Agreed Tariff (RP applies) – 80% of Agreed Tariff (RP applies) limited to R 6,100.00 per beneficiary to a maximum of R 18,100.00 per family per year
Combined sub-limit applies
Immunisations Not Applicable 80% of Agreed Tariff (RP applies) – 80% of Agreed Tariff (RP applies) limited to R 6,100.00 per beneficiary to a maximum of R 18,100.00 per family per year
Combined sub-limit applies
Oral & Injectable Contraceptives Not Applicable 80% of Agreed Tariff (RP applies) – 80% of Agreed Tariff (RP applies) limited to R 6,100.00 per beneficiary to a maximum of R 18,100.00 per family per year
Combined sub-limit applies
NON-PRESCRIBED MEDICINE (PAT)
Non-Prescribed Medicine (PAT) Not Applicable 80% of Agreed Tariff (RP applies) – limited to R 1,600.00 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: R 51,000.00 for a live donor, R 30,200.00 for a cadaver.  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. Limit will not apply to PMB
Chronic Renal Failure 100% of Medical Scheme Rate for Kidney Dialysis, incl. associated Radiology and Pathology tests – Unlimited
Oncology Benefit managed as part of an Oncology Management Programme. Overall limit of R 408,500.00 per family per year applies with a sub-limit of R 158,000.00 for Biological Drugs, if approved by the Scheme.
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 Cost of Oxygen Therapy (cylinders included) subject to Case Management
Human Papillomavirus (HPV), Prostate Test, Pneumococcal Conjugate Vaccine (PVC) and Annual Influenza Type B Single Dose Benefits subject to Authorisation on Disease Management Programme and provided that the condition forms part of Disease Management protocol. Further subject to member being registered on the Programme and member being compliant.
Mammogram and Pap Smears Benefit subject to Disease Management protocol
AIDS AND HIV – Benefits managed as part of a Disease Management Programme
FOREIGN CLAIMS – Namibian claims only
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 – subject to R 8,800.00 Clinical Psychology limit
Psychiatry 100% of Medical Scheme Rate – Unlimited – provided that treatment must form part of Case Management Programme. Treatment to be obtained in a mental health institution as approved by the Scheme 80% of Medical Scheme Rate – subject to R 8,800.00 Clinical Psychology limit
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 service provider, a 40% co-payment will apply. Scheme protocol apply.

 

CONTRIBUTIONS – EFFECTIVE 1 JANUARY 2018
Contributions Principal Member
R 6,997.00
Additional Adult Dependant
R 6,035.00
Additional Minor Dependant
(payable up to maximum of 3)
R 1,210.00
ABBREVIATIONS:

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