SelfNET 2017

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

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 Tarriff at Scheme’s DSP, limited to PMB Not Applicable
Outpatient treatment at hospital facility Not Applicable Benefits as described in respect of Medical Practitioners, limited to three consultations, subject to R 1,000.00 limit. Account payable upfront by member and submitted to Network for refund in accordance with the Network protocol and benefit limit.
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
MAJOR MEDICAL BENEFITS – NON-PMB
Adenoidectomy, Tonsillectomy and Grommets 100% of Network Rate – maximum benefit limit of R 12,000.00 per family per year, subject to pre-authorisation and procedure being performed in a day hospital Not Applicable
MEDICAL PRACTITIONERS
General Consultations / Visits 100% of Network Rate – Unlimited – subject to PMB protocol 100% of Network Rate via the Network GP for all medically necessary consultations per beneficiary. Cover includes basic primary care services. Minor trauma treatment subject to the listed tariffs
Specialist Practitioners Consultations / Visits 100% of Network Rate – Unlimited – subject to PMB protocol 100% of Network Rate via the Network provider, subject to a combined limit of R 1,070.00 per Beneficiary per year for cost of consultation, medication, procedures and radiology and pathology related to the authorised out of hospital specialised visit, limited to a maximum of R 2,140.00 per family per year
Basic Radiology 100% of Network Rate – Unlimited – subject to PMB protocol 100% of Network Rate, subject to the Network protocol, formulary and referral by a Network GP
MRI- and CT-scans and radio-isotope studies (Benefits subject to seperate pre-authorisation) 100% of Network Rate – 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 100% of Network Rate – 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 protocol 100% of Network Rate, subject to the Network protocol, formulary and referral by a Network GP
Clinical Procedures 100% of Network Rate – Unlimited but subject to PMB treatment and protocol No benefits will be allowed for elective Clinical Procedures, unless treatment forms part of PMB
Material and injection material administered in doctor’s rooms Not Applicable 100% of Network Rate, subject to the Network protocols, formulary and referral by a Network GP
MATERNITY
Foetal scans 100% of Network Rate – Unlimited – subject to PMB protocol 100% of Network Rate, subject to the Network protocols, formulary and referral by a Network GP
Ante-Natal Specialist Consultations Not Applicable Subject to combined Specialist Practitioners Consultations/ Visits benefit
Confinement Subject to pre-authorisation and network provider referral process, limited to PMB Not Applicable
AUXILIARY SERVICES
Physiotherapy 100% of Network Rate – Unlimited – subject to PMB protocol To be self funded
Medical Technology 100% of Network Rate – Unlimited – subject to PMB protocol To be self funded
Clinical Technology 100% of Network Rate – Unlimited – subject to PMB protocol To be self funded
Speech Therapy and Occupational Therapy 100% of Network Rate – Unlimited – subject to PMB 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 100% of the Network Rate for one examination per beneficiary per 24 months at the Network Optometrist
Spectacles and Contact Lenses Not Applicable One pair of clear standard mono-, bi- or multi-focal lenses plus standard frame from a selection OR One set of approved contact lenses to the value of R460.00 per Beneficiary per 24 months at the Network Optometrist. Frames other than the pre-selection of frames limited to R170.00
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 regulations 100% of Cost – Subject to approval by Case Manager and PMB regulations
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 regulations 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 100% of Cost – subject to pre-authorisation and limited to PMB
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 100% of Network Rate, subject to the Network protocol, list of codes and the use of a Network dentist
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 (excluding extractions) 100% of Cost limited to PMB and subject to pre-autorisation and Network Clinical Protocol
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 100% of the Newtork Rate (subject to Reference Pricing) for Medicince, provided that it is prescribed or supplied by a Network GP and is subject to the Network formulary
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 this donor is in RSA and further subject to the recipient being a beneficiary of the Scheme. Specific radiology and pathology tests associated with the transplant will also qualify for a benefit.
Chronic Renal Failure 100% of Network Rate for Kidney Dialysis, including associated Radiology and Pathology tests – Unlimited
Oncology Benefits are payable for PMBs only. Benefit managed as part of 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 cost 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 during hospitalisation are subject to pre-authorisation and referral by Network GP Benefits for treatment out of hospital are subject to pre-authorisation and referral by network GP (DSP). 100% of Network Rate for consultations and treatment by a General Practitioner, Psychiatrist, Psychologist, Psychiatric Nurse Practitioner or Social Worker.
PRESCRIBED MINIMUM BENEFITS (PMB) – Benefits subject to application and provided that the treatment and/ or chronic medicine is received from a designated service provider. Please refer to the Member Guide for more detail. If voluntarily obtained from any other service provider, a 40% co-payment will apply. Scheme protocol apply.

 

CONTRIBUTIONS – EFFECTIVE 1 JANUARY 2017
Contributions Principal Member
R 1,185.00
Additional Adult Member
R 1,185.00.
Additional Minor Dependant
(payable up to maximum of 3)
R 418.00
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