Out-of-hospital benefits

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  • book Glossary
    Agreed rate The agreed rate is the negotiated tariff fee payable to any designated service provider, including those listed on the network.
    GRP The generic reference price – the Fund bases its medicine benefits on the cost of generic medicines instead of brand-name medicines.
    Momentum Health Momentum Health is contracted to the Scheme for all managed healthcare services and the management of the Scheme's provider network.
    Scheme rate The Scheme rate is the tariff set by the Fund for reimbursement of claims, in the absence of any other agreed or contracted tariff with any service provider.
    SEP The single exit price is the legislated price of medicine.
    UPFS The uniform patient fee schedule is the fee schedule applied by the public sector.
    PMB CDL Prescribed Minimum Benefits (PMB) Chronic Disease List (CDL): PMBs are benefits that medical schemes must offer in terms of the Medical Schemes Act, 131 of 1998.

Primary Option

  • General practitioners (GPs)
    Network and non-network GP consultations

    A  co-payment equal to the difference between the Scheme rate and GP rate may apply

    Subject to overall annual day-to-day limit

    Single member: R18 900
    Member + 1: R29 500
    Member + 2: R38 300
    Member + 3: R39 500
    Member + 4: R40 000

    100%

    of Scheme rate
    Emergency consultations

    A  co-payment equal to the difference between the Scheme rate and GP rate may apply

    Subject to overall annual day-to-day limit

    Single member: R18 900
    Member + 1: R29 500 
    Member + 2: R38 300
    Member + 3: R39 500
    Member + 4: R40 000

    100%

    of Scheme rate
    Acute medication (GP and emergency)

    Subject to R400 per beneficiary per day

    Subject to overall annual day-to-day limit

    Single member: R18 900
    Member + 1: R29 500
    Member + 2: R38 300
    Member + 3: R39 500
    Member + 4: R40 000

    100%

    of SEP, formulary medication and GRP, subject to overall annual day-to-day limit
  • Over-the-counter (OTC) medication
    OTC medication (includes homeopathic, herbal and natural medication)

    Subject to R450 per beneficiary per day, with a maximum of R1 970 per family per year

    Subject to overall annual day-to-day limit

    Single member: R18 900
    Member + 1: R29 500
    Member + 2: R38 300
    Member + 3: R39 500
    Member + 4: R40 000

    100%

    of SEP and GRP, subject to overall annual day-to-day limit
  • Specialists
    Consultations (non-network provider)

    A co-payment equal to the difference between the Scheme rate and specialist rate may apply

    The member is responsible for ensuring that an authorisation number is obtained before consulting a specialist

    Subject to overall annual day-to-day limit

    Single member: R18 900
    Member + 1: R29 500
    Member + 2: R38 300
    Member + 3: R39 500
    Member+ 4: R40 000

    Up to 160%

    of Scheme rate, subject to overall annual day-to-day limit
    Consultations (network provider)

    The member is responsible for ensuring that an authorisation number is obtained before consulting a specialist

    Subject to overall annual day-to-day limit

    Single member: R18 900
    Member + 1: R29 500
    Member + 2: R38 300
    Member + 3: R39 500
    Member + 4: R40 000

    100%

    of Agreed rate, subject to overall annual day-to-day limit
    Acute medication

    The medication may be obtained at any pharmacy

    Subject to overall annual day-to-day limit

    Single member: R18 900
    Member + 1: R29 500
    Member + 2: R38 300
    Member + 3: R39 500
    Member + 4: R40 000

    100%

    of single exit price (SEP) and generic reference price (GRP), subject to overall annual day-to-day limit
  • Gynaecology

    Limited to R2 000 per beneficiary per year

    Subject to overall annual day-to-day limit

    Single member: R18 900
    Member + 1: R29 500
    Member + 2: R38 300
    Member + 3: R39 500
    Member + 4: R40 000

    100%
    of Agreed rate
  • Emergency room/Casualty department (hospital unit)

    Excludes facility fee
    Primary care benefits for acute illnesses or injuries which may require immediate attention

    Subject to overall annual day-to-day limit

    Single member: R18 900
    Member + 1: R29 500
    Member + 2: R38 300
    Member + 3: R39 500
    Member + 4: R40 000 

    100%
    of Agreed rate
  • Dental
    Basic dentistry, specialised dentistry, dentures, procedures under conscious sedation in a doctor's rooms
    Dentistry

    Members are liable for all costs related to dental care by any general or specialist dentist where costs exceed the dental rate and/or dental limit

    Includes the following:
    - Basic dentistry
    - Advanced/Specialised dentistry
    - Dentures
    - Procedures under conscious sedation in a doctor's rooms
    - Clinical guidelines apply

    Dental limit:

    Single member: R7 900
    Member + 1: R9 500
    Member + 2: R11 200
    Member + 3: R11 400
    Member + 4: R11 700

    Subject to overall annual day-to-day limit

    Single member: R18 900
    Member + 1: R29 500
    Member + 2: R38 300
    Member + 3: R39 500
    Member + 4: R40 000

    100%

    of Scheme rate; dental limit subject to overall annual day-to-day limit
    Dental therapist

    Members are liable for all costs related to dental care by any general or specialist dentist where costs exceed the dental rate and/or dental limit

    Dental limit:

    Single member: R7 900
    Member + 1: R9 500
    Member + 2: R11 200
    Member + 3: R11 400
    Member + 4: R11 700

    Subject to overall annual day-to-day limit

    Single member: R18 900
    Member + 1: R29 500
    Member + 2: R38 300
    Member + 3: R39 500
    Member + 4: R40 000

    80%

    of Scheme rate; dental limit subject to overall annual day-to-day limit
  • Optometrists
    Frames, lenses, contact lenses, tints and eye tests

    Optometrists must obtain authorisation for patient referral to a specialist

    Optical limit: R3 420 per beneficiary every two years; i.e. 2025 to 2026

    Subject to overall annual day-to-day limit

    Single member: R18 900
    Member + 1: R29 500
    Member + 2: R38 300
    Member + 3: R39 500
    Member + 4: R40 000


    100%

    of Scheme rate; optical limit subject to overall annual day-to-day limit
  • Radiology

    Subject to overall annual day-to-day limit

    Single member: R18 900
    Member + 1: R29 500
    Member + 2: R38 300
    Member + 3: R39 500
    Member + 4: R40 000

    100%

    of Scheme rate, subject to overall annual day-to-day limit
  • Pathology

    Subject to overall annual day-to-day limit

    Single member: R18 900
    Member + 1: R29 500
    Member + 2: R38 300
    Member + 3: R39 500
    Member + 4: R40 000

    100%

    of Scheme rate, subject to overall annual day-to-day limit
  • Allied health services
    Nursing services, speech therapist, dietician, occupational therapist, social worker, audiologist, chiropody, chiropractor and physiotherapy and antiretroviral therapy

    Subject to overall annual day-to-day limit

    Single member: R18 900
    Member + 1: R29 500
    Member + 2: R38 300
    Member + 3: R39 500
    Member + 4: R40 000

    100%

    of Scheme rate, subject to overall annual day-to-day limit
  • Appliances
    Nebulisers, crutches, glucometers, hearing aids, hire of oxygen cylinders, etc.

    Subject to registration with the appropriate Disease Risk Management Programme

    Written motivation froMembera general practitioner is required; subject to approval froMembera medical advisor

    Subject to overall annual day-to-day limit

    Single member:R18 900
    Member + 1: R29 500
    Member + 2: R38 300
    Member + 3: R39 500
    Member + 4: R40 000

    100%

    of Scheme rate, subject to overall annual day-to-day limit
  • Clinical psychology

    The member is responsible for ensuring that an authorisation number is obtained before consulting a specialist

    Subject to overall annual day-to-day limit

    Single member: R18 900
    Member + 1: R29 500
    Member + 2: R38 300
    Member + 3: R39 500
    Member + 4: R40 000


    of Scheme rate, subject to overall annual day-to-day limit
  • Chronic medication

    To obtain benefits for chronic medication, the patient must be registered with the Medicine Risk Management Programme

    The Fund's approved chronic condition list is applicable
    Medication approved as per Chronic Disease Medication Formulary
    All medication may be obtained from a pharmacy or a dispensing network general practitioner

    PMB CDL conditions: Unlimited

    Non-CDL conditions: Limited to R3 310 per beneficiary per year

    100%

    of single exit price (SEP)and generic reference price (GRP)
  • Ambulance services

    Members must make use of Netcare 911

    Members must call 082 911 for all ambulance services

    For voluntary use of any other service provider, members will be liable for a 20% co-payment

    Netcare 911

      only
  • HIV/AIDS
    This benefit includes medication, doctor's consultations and blood tests at contracted service providers required for the treatment of the condition, as well as the cost of prophylaxis for preventative treatment

    This benefit is subject to enrolment on the HIV/AIDS Programme

    Medicine and hospital pre-authorisation are required

    R16 800

    100%

    of Scheme rate
    Medicine: 100% of single exit price (SEP) and generic reference price (GRP)
  • PREVENTATIVE CARE BENEFIT
    Consultations and/or any other costs incurred at the time of the visit will be paid from your benefits, as specified in the rules of the Fund.
    Out-of-hospital preventative care procedures

    100% of Scheme rate

    Paid from overall annual day-to-day limit
        Flu vaccine

      Limited to 1 per beneficiary per year

    Pap smear

    Limited to 1 per female beneficiary per year

    At Dis-chem or Clicks pharmacies or tariff codes 4566/4559

    Health risk assessment (HRA) - Body mass index, blood pressure measurement, cholesterol screening (finger-prick test) and blood sugar screening (finger-prick test)

    Limited to 1 screening per adult beneficiary per year

    At Dis-Chem or Clicks pharmacies
    Should your HRA be performed in the doctor's room, the consultation fee will be paid from your available GP visits benefit

    Cholesterol test

    Limited to 1 per beneficiary per year

    Only one of the following tariff codes will be allowed: 4025, 4026, 4027, 4028 or 4170

    Mammogram

    Limited to 1 per female beneficiary every 2 years or as clinically indicated

    Subject to the following criteria:
    Females over 40 years
    Motivation and pre-authorisation required

    One of the following tariff codes will be allowed: 3605 or 34100/01/10/20/30/50

    Bone density scan: Dual-energy X-ray absorptiometry (DEXA scan)

    Limited to one per adult beneficiary 50 years and above every 3 years

    Subject to the following criteria:
    Beneficiaries over 50 years
    Motivation and pre-authorisation required
    All adults (18 and above) with diseases associated with low bone mass or bone loss
    All adults (18 and above) with fragility fractures – little or no trauma

    One of the following tariff codes will be allowed: 3604 /39173/150120

    HIV test

    Limited to 1 per beneficiary per year

    Tariff code 3932

      Colorectal screening

    Limited to 1 per beneficiary per year

    Subject to the following criteria: Beneficiaries 50 years and older Tariff code 4351 or 4352

      Human papillomavirus (HPV)

    Maximum of 3 per beneficiary, depending on vaccination manufacturer

    Subject to the Human papillomavirus formulary

    Male and female beneficiaries between the ages of 9 and 18

      Prostate-specific antigen (PSA) test

    Limited to 1 per male beneficiary per year

    Tariff code 4519 or 4524

      Male circumcision (in GP's rooms)

    Limited to 1 per male beneficiary per year

    Tariff code 2133, 2137 or 2139

     

    Child and infant vaccinations

    Subject to the Baby and child vaccine formulary

    State protocols apply

    Pneumococcal vaccine (Pneumovax only)

    Limited to 1 per beneficiary per annum

    Beneficiaries over 65 years

    High risk patients only: Patients diagnosed with cancer, asthma, chronic obstructive pulmonary disease, cardiac failure or HIV

Benefit Summary - 0.61mb