The scheme might still cover some or all day-to-day claims. See below, and see benefits.
Children Rates:
Under 21 yrs, unless student or financially dependent. Then, under 27yrs.
Only pay for 3 children
Note:
Exclusions: Note that all schemes have extensive exclusions. We've tried to list the major ones, but you must consult with your scheme to get the full list.
All treatments and procedures are subject to authorisation and protocols
All benefits are listed as an indication only. Please verify with your broker and scheme
* There might be other co-payments if you don't use scheme-chosen provider for some services.
* Treatment required for PMB level care is always paid by scheme, with no co-payment, if you follow the protocols. That means that these co-payments might not apply in your case! More info here
Specialised Radiology:
MRI, CT and PET Scans: R24,000 per family, unless PMB or otherwise authorised
No benefit for screening purposes
No limits or co-payments for PMB level care and/or for emergency
Supplementary Services: (Physio, etc)
R3,000 per family
No limits or co-payments for PMB level care and/or for emergency
Transplants:
PMBs only
Dialysis:
PMBs only
Exclusions:
Deep brain implants (e.g. Parkinson’s Disease) and internal nerve stimulators
Corneal transplants
Cochlear implants
Bunion surgery
All spinal surgery (including neck), except in the event of acute injury
All joint replacements, except in the event of acute injury.
Laminectomy and spinal fusion
* Treatment required for PMB level of care is always paid by scheme, if you follow the protocols. It cannot be excluded. More info here.
* All schemes have extensive exclusions. We've tried to list the major ones here, but please consult your scheme or broker to get the full list
Alternatives to hospitals:
Home nursing: 20 days per family
Step-down nursing, hospice and rehab: as authorised
Casualty:
One visit per child under 6 yrs: R1 300 paid by scheme
All medical aids must pay for the diagnosis, treatment and management of all PMB conditions, in or out of hospital. You can see a full list of the conditions here.
This can include consults with specialists, blood or other tests, radiology and medicine
The benefit is paid by the scheme, and not out of your savings account
If you have no day-to-day funds, you still have cover for PMBs
Schemes usually impose the use of specific providers for treatment of PMBs. Read more about that here.
One wellness consult, excluding procedures, paid by scheme
Unlimited GP consultations and basic dentistry for children under 6yrs, paid by scheme
Treatment required for PMB conditions is always paid paid by scheme, with no co-payment, if you follow the protocols. More info here
Childcare:
Baby Wellness consults: 2 per year, for 4m-18m
Unlimited GP consultations and basic dentistry for children under 6yrs
Initial Occupational Therapy consultation
School readiness assessments
Kid’s active benefit assessment and exercise prescription
programme
Kid’s nutritional benefit assessment and healthy eating programme
Specialists consultations:
PMBs only
Treatment required for PMB conditions is always paid paid by scheme, with no co-payment, if you follow the protocols. More info here
Pathology:
PMBs only
General radiology:
PMBs only
Specialised radiology:
PMBs only
Scans required for PMB level care are paid paid by scheme, with no co-payment, if you follow the protocols. More info here
Supplementary Services: (Physio, etc)
Speech therapists, social workers, podiatrists, occupational therapists, homeopaths and naturopaths, dietitians, chiropractors (X-rays excluded), audiologist, physiotherapy and biokinetics in-and-out of hospital:
PMBs only
General Appliances:
No benefit
1.1. Hearing Aids:
No benefit
1.2. Wheelchairs:
See above
Note:
PMBs: Prescribed Minimum Benefits. To read more about PMBs click here
DSPs: Designated Service Provders. Where stipulated, you must use specific specific providers to get full benefit.
Co-payment: Paid out of pocket, or out of savings account. Sometimes this is refundable to you if you have a gap product
All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme. The benefits listed here are an indication only. Please verify all benefits and their conditions with the scheme.
You might be required to use specific pharmacies and be limited to specific medicines
Acute (presrcibed) medication:
No benefit
Over-the-counter:
No benefit
Birth Control:
R2,950 per person, including devices
On Discharge:
7 days per admission
Biological:
R160,000 per family, with 25% co-payment
Treatment that is required (by law) for PMB conditions is always paid paid by scheme, with no co-payment, if you follow the protocols. More info here.)
Note:
Schemes have very strict rules about where you can get your medicine to get full benefit. We do not list the requirements here, so confirm with your scheme before you collect your medicine.
Formulary: A pre-defined list of approved medicines. Each plan has a different list, and might not pay for non-listed medicine. Confirm with your scheme whether your required medicine is covered by them.
PMBs: Prescribed Minimum Benfits. To read more about PMBs click here
DSPs: Designated Service Provders. Where stipulated, you must use specific specific providers to get full benefit.
Co-payment: Paid out of pocket, or out of savings account. Sometimes this is refundable to you if you have a gap product
All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme. The benefits listed here are an indication only. Please verify all benefits and their conditions with the scheme.
A quick guide to how you can change your medical aid plan, including the resignation procedure, and things to look out for, such as imposed waiting periods from your new scheme
