Selfsure 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

Annual Day-to-day Limit: Principal Member = R 5,100.00;
Additional per adult dependant = R 3,600.00;
Additional per minor dependant = R 1,800.00 (to a maximum of R 5,400.00)
• Radiology, Pathology, Basic Dentistry, Physiotherapy and Biokinetics = R 5,200.00 or R 7,300.00 for family
• Optometry = 100% of Scheme Tariff in repspect of consultation and spectacles/ contact lenses limited to R 5,100.00 per family per familty per 24 month cycle
• Medical appliances = R 4,300.00 per family

HOSPITALISATION
Accommodation, theatre, medicine and material used whilst hospitalised 100% of Agreed Tariff Not Applicable
Outpatient treatment at hospital facility Not Applicable 100% of Medical Scheme Rate, Subject to Annual Day-to-day Limit
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 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 – Subject to joint limit for Basic Dentistry, Physiotherapy and Biokinetics
ECHO-Tests 100% of Medical Scheme Rate – Unlimited 100% of Medical Scheme Rate – limited to R3,000.00 per beneficiary per year
MRI- and CT-scans and radio-isotope studies (Benefits subject to seperate pre-authorisation) 100% of Medical Scheme Rate – R 1,600.00 co-payment applies 100% of Medical Scheme Rate – R 1,600.00 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
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 limited to Annual Day-to-day limit

Cochlear Implants 100% of Medical Scheme Tariff– Limited to R 30,200.00 per implant Not Applicable
Material and injection material administered in doctor’s rooms Not Applicable 100% of Medical Scheme Rate – Subject to Annual Day-to-day Limit
MATERNITY
Ante-Natal Classes and Foetal scans 100% of Medical Scheme Rate – Unlimited 100% of Medical Scheme Rate. Foetal Scans limited to 2 per beneficiary per year and the cost of a 3D scan is limited to the cost of a 2D scan. Benefits allowed for additional pregnancy scans and/or pre-childbirth education at 100% of Cost to a maximum of R1,700.00 per Family per Year
Ante-Natal Consultations 100% of Medical Scheme Rate – Unlimited 100% of Medical Scheme Rate – Unlimited
Confinement 100% of Agreed Tariff in respect of hospitalisatio and 100% MSR in respect of Associated Provider services – Unlimited
AUXILIARY SERVICES
Physiotherapy and Biokinetics 100% of Medical Scheme Rate – Unlimited 100% of Medical Scheme Rate – Subject to joint limit for Radiology, Pathology and Basic Dentistry
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
Speech Therapy and Occupational Therapy 100% of Medical Scheme Rate – Unlimited (treatment to form part of a Case Management Programme) 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 100% of Medical Scheme Rate – Subject to Annual Day-to-day Limit 100% of Medical Scheme Rate – Subject to Annual Day-to-day Limit
Aromatherapy, acupuncture and relexology To be self funded To be self funded
OPTICAL -100% of cost limited to R 2,600.00 per beneficiary or R 5,100.00 per family over two years
Consultation Not Applicable 100% of Cost. For a standard eye examination per beneficiary per 24 month period – Subject to combined family limit per 24 month cycle
Spectacles and Contact Lenses Not Applicable 100% of Medical Scheme Rate – For a pair of generic standard lenses
100% of Cost – For a frame limited to R500 per beneficiary per 24 month period – OR
100% of Medical Scheme Rate – For clear contact lenses limited to R900 per beneficiary per 24 month periods – 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 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 R2,800.00 per family per year, limit will not apply to PMB
BLOOD TRANSFUSIONS – 100% of Costs, 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 details
External Prosthesis 100% of Cost, limited to R 56,300.00 per family per year – subject to approval by Case Manager
Orthopaedic Applicances 100% of cost limited to R 8,000.00 per family per year – subject to Case Management
Medical Appliances Not Applicable 100% of Cost, limited to R 4,300.00 per family per year. This maximum may be exceeded, subject to a maximum of R 12,900.00, in respect of certain appliances, provided that the treatment forms part of a Case Management Programme
Hearing Aids Not Applicable To be self funded
DENTISTRY
Basic 100% Medical Scheme Rate –R1,100.00 co-payment applies and subject to joint limit for Radiology, Pathology, Physiotherapy and Biokinetics 100% Medical Scheme Rate – Subject to joint limit for Radiology, Pathology, Physiotherapy and Biokinetics
Specialised 100% Medical Scheme Rate – R1,100.00 co-payment applies and subject to Annual Day-to-day Limit 100% Medical Scheme Rate –Subject to Annual Day-to-day Limit
MAXILLA-FACIAL AND ORAL SURGERY
Elective 100% Medical Scheme Rate – R1,100.00 co-payment applies and subject to Annual Day-to-day Limit 100% Medical Scheme Rate – Subject to Annual Day-to-day Limit
Non-elective (excluding extractions) 100% Medical Scheme Rate – R1,100.00 co-payment applies. In the event of PMB 100% of Cost – Subject to PMB protocol 100% Medical Scheme Rate – Unlimited _ In the event of PMB 100% of Cost – Subject to PMB protocol
Implantology 100% Medical Scheme Rate – R 1,100.00 co-payment applies, PMB 100% of Cost -Subject to PMB protocol 100% Medical Scheme Rate – Subject to Annual Day-to-day Limit
PRESCRIBED MEDICINE
Chronic (Member must apply for benefit) Not Applicable No benefit, except PMB
Acute Not Applicable 100% of Agreed Tariff (RP applies) – subject to Annual Day-to-day Limit
Immunisations Not Applicable 100% of Agreed Tariff (RP applies) – subject to Annual Day-to-day Limit
Oral & Injectable contraceptives Not Applicable 100% of Medical Scheme Rate – Limited to R 1,600.00 per family per year
NON-PRESCRIBED MEDICINE(PAT)
Non-Prescribed Medicine (PAT) Not Applicable 100% of Agreed Tariff (RP applies) – limited to R 270.00 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. R 44,900.00 for a live donor, R 26,800.00 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 100% of Agreed Tariff – Benefit managed as part of an Oncology Benefit Management Programme and subject to use of Preferred Provider. Overall limit R 242,400.00 per family per year. Limit will not apply to PMB. 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
Human Papillomavirus (HPV) 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.
FOREIGN CLAIMS – Namibian claims only
AIDS AND HIVS – Benefits management as part of a Disease Management Programme
MENTAL HEALTH
Clinical Psychology 100% Medical Scheme Rate – Unlimited – provided that treatment forms part of Case Management Programme 100% Medical Scheme Rate – Subject to Annual Day-to-day Limit
Psychiatry 100% Medical Scheme Rate – Provided that treatment forms part of Case Management Programme. Treatment to be obtained in a mental health instituion, as approved by the Scheme 100% Medical Scheme Rate – Subject to Annual Day-to-day 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 2,699.00
Additional Adult Member
R 2,695.00
Additional Minor Dependant (payable up to maximum of 3)
R 920.00

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