Resolution Hospital medical aid plan: 2018

View all plans in this scheme.
Please note that these benefits are still being updated as more information is made available to us. Always consult with your broker before making final decisions regarding your healthcare cover.

COSTS and OVERVIEW:
Hospital
Quick Overview
Main: Adult: Child:
Total Cost pm: R R R

Gap (optional):
  • Varies. See below for specific recommendation for this plan.
In brief: See full benefits below

IN HOSPITAL PROCEDURES:
Hospital
Scheme Benefits: Gap Benefits:
Specialists:
  • 100% scheme rate
  • You or gap cover pay the balance, if any
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
  • Recommended for this plan: Plan Blue, R295pm per family where no member is older than 64yrs (otherwise, R435pm per family)
Hospital Choice:
  • Choose any hospital
  • No benefit
Specialised Radiology:
  • Limited to R7,915 per family with R1,996 co-payment paid by you or your gap cover
  • In and out of hospital
  • Co-payment paid
  • Sublimit increased as necessary, for approved procedures
  • No benefit for exclusions
  • Out of hospital, co-payment and sublimit increase is for MRI and CT scans only
Supplementary Services: (Physio, etc) TBC
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals, for non-PMB treatment
  • No benefit for out-of-hospital services
Transplants:
  • State hospitals only
  • No benefit
Co-payments:
  • No co-payments if performed out of hospital (except for specialised radiology), or if PMB
  • Specialised radiology: R1,996
  • Excision nail bed, skin lesions, tympanoplasty:R1,984 co-payment
  • Myringotomy, tonsillectomy, adenoidectomy: R2,313 co-payment
  • Dental admissions, circumcision, colonoscopy, sigmoidoscopy, proctoscopy, cystoscopy, gastroscopy: R2,642 co-payment
  • Hysteroscopy: R2,971 co-payment
  • Arthroscopy, endometrial ablation, laparoscopic procedures, urinary incontinence repair, varicose veins, conservative back or spinal treatment, hernia repair, hysterectomy: R3,957 co-payment
  • Nasal surgery: R5,942 co-payment
  • Joint replacements, rotator cuff surgery: R7,550 co-payment
  • Spinal surgery: R8,255 co-payment
  • Reflux surgery: R11,343 co-payment
  • Co-payments paid by you or your gap cover
  • Gap cover pays co-payments for procedures approved by medical aid
Alternatives to hospitals:
  • Home nursing: in lieu of hospitalisation
  • Hospice, rehab and step down facility: 10 days per family
Casualty:
  • No benefit, unless PMB
  • Pays up to R20,000 per person per year for emergency medical treatment not paid for by medical aid
Other:
  • N/A
  • N/A
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R150,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R150,000 limit)
  • Gap only supplements payment for procedures approved or authorised by your medical aid, and does not cover “penalties” (such as if, for example, you choose a non-DSP doctor for your procedure when the plan required a DSP doctor)

No phone calls!
Our quote will include the right gap cover for this plan

All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme.
The gap benefits listed are for AskAdam gaps, unless otherwise stated. Actual benefits depend on gap choice option.

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OUT OF HOSPITAL BENEFITS (non-PMB):
Hospital
Scheme Benefits Gap benefits
Main: Adult: Child:
General info:
  • Our recommended gap cover does not pay out-of-hospital claims, unless it is for cancer treatment, dialysis, or MRI/CT scans
GP consultations:
  • 2 consults per person, unlimited for PMBs
Childcare:
  • No extra benefit available
Specialists consultations:
  • No benefit, unless PMB
Pathology:
  • No benefit, unless PMB
General radiology:
  • No benefit, unless PMB
Specialised radiology:
  • R7,915 per family with R1,996 co-payment. In and out of hospital
Supplementary Services: (Physio, etc)
  • No benefit, unless PMB

No phone calls!
Our quote will include the right gap cover for this plan

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MATERNITY BENEFITS:
Hospital
Scheme Benefits Gap benefits
Hospital stay:
  • Vaginal birth: 3 days, 2 nights
  • Caesarean birth: 4 days, 3 nights
  • Elective Caesarean: no benefit
Consultations:
  • PMBs only
  • Antenatal classes: no benefit
Scans:
  • 2 x 2D scans, paid by scheme

No phone calls!
Our quote will include the right gap cover for this plan

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CANCER (ONCOLOGY):
Hospital
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • R180,081 per family

No phone calls!
Our quote will include the right gap cover for this plan

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DENTISTRY:
Hospital
Scheme Benefits Gap benefits
Dentistry:
  • Standard dentistry:No benefit
  • Specialised dentistry: No benefit
  • Impacted wisdom teeth: R4,616 per family with R2,642 co-payment, in hospital
Orthodontics:
  • You pay this out of pocket
  • No extra benefit available
Maxillo Facial Surgery: 2018 benefits are coming soon!
  • Pays shortfalls and co-payments for any non-PMB in-hospital dentistry treatment approved by scheme. (PMB are paid in full by scheme if you use DSP)

No phone calls!
Our quote will include the right gap cover for this plan

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MEDICATION:
Hospital
Scheme Benefits Gap benefits
Chronic:
  • PMB chronic: paid by scheme
Acute (presrcibed) medication:
  • No benefit
Over-the-counter:
  • No benefit
Birth Control:
  • R1,000, subject to R2,493 sublimit for preventative benefits
On Discharge:
  • 7 days supply
Biological:

No phone calls!
Our quote will include the right gap cover for this plan

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OPTOMETRY:
Hospital
Scheme Benefits Gap benefits
Optometry:
  • No benefit
  • Pays shortfalls and co-payments for any non-PMB in-hospital treatment approved by scheme. (PMBs are paid in full by scheme if you use DSP)

No phone calls!
Our quote will include the right gap cover for this plan

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MENTAL HEALTH:
Hospital
Scheme Benefits Gap benefits
In-hospital:
  • PMBs only
Out-of-hospital:
  • PMBs only
Trauma:
  • Access to Nurse help line, and Rape Crisis Centre

No phone calls!
Our quote will include the right gap cover for this plan

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OTHER BENEFITS:
Hospital
Scheme Benefits Gap benefits
General Appliances:
  • External: R4,122 per family, subject to PMBs and various sub-limits per appliance
    • No benefit
    1.1. Hearing Aids: See above, every 3 years
    • No benefit
    1.2. Wheelchairs: See above, every 3 years
    • No benefit
    Dialysis:
    • PMBs only, at network providers
    HIV:
    • Covered if on HIV Management Programme
    • No benefit
    Emergency Transport: Netcare 911
    • No benefit
    International Insurance:
    • Available, contact scheme
    • No benefit
    Other:
    • Cochlear implants: no benefit

    No phone calls!
    Our quote will include the right gap cover for this plan

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    WELLNESS/PREVENTATIVE BENEFITS:
    Hospital
    Scheme Benefits Gap benefits
    Flu vaccination:
    • Covered, with a R2,493 limit for all preventative benefits
    • No benefit
    Pneumonia vaccines: 2018 benefits are coming soon!
    • No benefit
    Back Rehabilitation Programme: 2018 benefits are coming soon!
    • No benefit
    Biometric Screening: 2018 benefits are coming soon!
    • No benefit
    Child Immunisation:
    • Covered, with a R2,493 limit for all preventative benefits, and a sublimit of R1,875
    • No benefit
    Pap Smear:
    • Covered for 45yrs+, with a R2,493 limit for all preventative benefits
    • No benefit
    Mammogram: 2018 benefits are coming soon!
    • No benefit
    PAS Test:
    • Covered for 45yrs+, with a R2,493 limit for all preventative benefits
    • No benefit
    HIV Test: 2018 benefits are coming soon!
    • No benefit
    Other:
    • No benefit

    No phone calls!
    Our quote will include the right gap cover for this plan

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    PROSTHETICS:
    Hospital
    Scheme Benefits Gap benefits
    Overal Limit:
    • R37,685 per family
    Sub-limits:
    • Various sublimits apply, speak to scheme

    No phone calls!
    Our quote will include the right gap cover for this plan


      Important!
    • Unless specified, assume that all benefits are paid are paid at 100% scheme rate
    • No limits or co-payments can apply to treatment of PMBs, which is always unlimited, although subject to strict protocols and scheme rules.
    • “Unlimited” benefits are still subject to authorisation, protocols and sublimits
    • Assume that all benefits need to be pre-authorised