Comprehensive Option
Hospitalisation Benefits
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Benefits will be allocated pro rata for beneficiaries or members joining during the year.
You must obtain authorisation for any non-emergency hospital admission and related treatment by calling 0802 228 922.If you do not obtain authorisation at least two days before any non-emergency hospital admission or related treatment, penalties may be applied and benefits may be withheld.
- YOUR MAJOR MEDICAL EXPENSES BENEFIT
Your major medical expenses benefit consists out of three categories:
Procedures performed in hospital Certain procedures performed in doctors' rooms, hospital medical facilities or day clinics, but paid from your major medical expenses benefit Additional procedures that are not performed in or out of hospital, but paid from your major medical expenses benefit. - SPECIFIED TIME LIMITS FOR PRE-AUTHORISATION
- DESIGNATED SERVICE PROVIDERS - NETWORK SPECIALIST
- HOW TO OBTAIN HOSPITAL PRE-AUTHORISATION
IN-HOSPITAL BENEFITS
| Benefits | Description | |
|---|---|---|
| Ambulance services - Netcare 911 - 082 911 | 100% of the agreed tariff. Subject to authorisation by Netcare 911 within 72 hours of the transport occurring. Unauthorised use of an ambulance for non-emergency treatment will not be covered by the Fund. For authorisation, please call 082 911 | 100% of the agreed tariff |
| Hospitalisation - private, provincial or State hospitals |
Paid at 3x the WHFT for authorised admissions - no hospital network applicable Authorisation: 0802 228 922 |
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| Ward accommodation |
Paid at general ward tariffs, subject to pre-authorisation Authorisation: 0802 228 922 |
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| Take-home medication (after discharge from hospital) |
Limited to 7 days |
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| GPs - including surgery, procedures and consultations |
Paid at 3x the WHFT Subject to pre-authorisation Call 0802 228 922 for GP referral and authorisation |
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| Specialists - including surgery, procedures and consultations |
Paid at 3x the WHFT at non-network specialists |
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| Radiology - including MRIs, CT scans, radio-isotope studies, ultrasounds and bone density scans (DEXA) |
Paid at 3x the WHFT |
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| Pathology | Paid at 3x the WHFT | |
| Organ transplants |
Subject to pre-authorisation, managed care protocols, PMBs and networks Where the recipient is a beneficiary of the Fund, services rendered to the donor and the transportation of the organ are included in this benefit Where the donor is a beneficiary of the Fund, but the recipient is not, the donor costs will not be covered by the Fund, since these costs should be covered by the recipient's medical scheme |
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| Hospitalisation, organ and patient preparation | Paid at 3x the WHFT | |
| Immunosuppressant drugs dispensed in hospital or dispensed by the hospital to take out for use after discharge | 100% of cost | 100% of Costs |
| Subsequent supplies of immunosuppressant drugs | 100% of cost, subject to pre-authorisation | 100% of Costs |
| Robotic-assisted laparoscopic prostatectomy |
Paid at 1x the WHFT Subject to pre-authorisation and clinical motivation Must be performed at an accredited hospital Limited to R171 700 per qualifying beneficiary per year for hospital and equipment |
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| Blood transfusions, transportation of blood and blood products | Paid at 3x the WHFT | |
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Auxiliary services in hospital:
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Paid at 1x the WHFT for authorised admissions The service/procedure must be directly related to the authorised admission Post-operative auxiliary services may be approved and benefits granted on condition that these services are received within six weeks after the hospital admission Subject to clinical motivation and pre-authorisation |
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| Psychiatric treatment in hospital or at a registered facility OR Outpatient treatment in lieu of hospitalisation |
Subject to pre-authorisation and limited to 21 days per beneficiary per year 1 psychiatric or psychology consultation post admission within 6 weeks post discharge Authorisation: 0802 228 922 |
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| Maxillofacial treatment |
Paid at 3x the WHFT, subject to pre-authorisation |
IN-DOCTORS' ROOMS, HOSPITAL MEDICAL FACILITIES OR DAY CLINICS
| Benefits | Description | |
|---|---|---|
| Certain procedures performed in doctors' rooms only | Paid at 3x the WHFT Anaesthetic costs related to these procedures will be limited to local or regional anaesthetic. General anaesthetic costs are not covered |
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| Hospitalisation is subject to approval of clinical motivation and managed care protocols |
Cone biopsy, cauterisation of warts, colposcopy, nasal polypectomy, nasal cautery, meibomian cyst excision, circumcision, drainage of superficial abscess, superficial foreign body removal and breast biopsy Authorisation: 0802 228 922 |
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| Oncology, radiotherapy and chemotherapy in and out of hospital - medication/chemicals, related radiology, including MRIs and CT scans and pathology |
Limited to PMBs only. Subject to pre-authorisation and registration on the Oncology Risk Management Programme. A detailed clinical motivation and treatment plan is required from the treating specialist. South African Oncology Consortium (SAOC) clinical guidelines apply as reference. Standard and/or State of the Art level of care treatment up to R546 000 per Family per annum. Continued benefits for PMB level of care treatment thereafter. Specialised oncology medication: 30% of cost payable per cycle subject to the oncology benefit limit and qualifying clinical criteria. |
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Endoscopic examinations:
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Paid at 3x the WHFT if performed in doctors' rooms/outpatient/medical or surgical facilities R2 920 co-payment applies if performed in hospital without an approved clinical indication and Fund approval |
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| These procedures can be performed in doctors' rooms, and in outpatient/medical/surgical facilities |
Anaesthetic costs related to these procedures will be limited to local or regional anaesthetic. |
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| If performed in hospital, it will attract a member co-payment |
Pathology costs related to these procedures will be covered from major medical expenses |
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Ophthalmologist examinations:
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Paid at 3x the WHFT if performed in doctors' rooms/outpatient/medical or surgical facilities A co-payment of R2 920 will apply should any of these procedures be performed in hospital, without an approved clinical indication and Fund approval Anaesthetic costs related to these procedures will be limited to local or regional anaesthetic General anaesthetic costs are not covered Pathology costs related to these procedures will be covered from major medical expenses |
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| Basic dentistry procedures in hospital - removal of teeth and multiple fillings for children 7 years and younger |
Paid at 3x the WHFT, subject to pre-authorisation The dentist will be paid from your available MSA Conscious sedation subject to pre-authorisation, anaesthetist's costs to be paid from major medical expenses |
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| Specialised dentistry procedures in and out of hospital - dental implants and removal of impacted wisdom teeth | Paid at 1x the WHFT, subject to pre-authorisation and limited to R26 380 per beneficiary per year | |
| Refractive surgery |
Paid at 1x the WHFT, subject to pre-authorisation LASIK surgery benefit subject to guidelines for refractive surgery required for medical reasons A motivation, including the refractive error, is required Subject to approval by medical advisor and based on refraction levels |
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| Peritoneal dialysis and haemodialysis |
Paid at 3x the WHFT, subject to pre-authorisation, managed care protocols and PMBs |
ADDITIONAL BENEFITS
PAID FROM MAJOR MEDICAL EXPENSES BENEFIT
| Benefits | Description |
|---|---|
| Private nursing |
Paid at 1x the WHFT and limited to R6 460 per beneficiary per month. Limited to 6 months per annum Subject to clinical motivation by GP or specialist |
| Internal prostheses Appliances placed in the body as an internal adjuvant during an operation |
Paid at 3x the WHFT, subject to pre-authorisation and limited to R85 370 per beneficiary per year Authorisation: 0802 228 922 |
| External Prostheses and Appliances This benefit is issued on a 24-month benfit cycle, that runs from date of service. |
Paid at 3x the WHFT, subject to written motivation, which must be received 72 hours before the request for pre-authorisation and approval Benefits are subject to terms, conditions and Managed Health Care protocols Limited to R89 400 per beneficiary, every two years with the following sub-limits:
Authorisation: 0802 228 922 |
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Medical and surgical appliances - including nebulisers, crutches, blood pressure machines, glucometers, etc. |
Paid at 3x the WHFT, subject to clinical motivation and pre-authorisation Subject to available MSA where pre-authorisation is not obtained |