Extended Fund: Extra funds from the scheme for (mostly) out of hospital claims, over and above any savings account
R3,000
R2,340
R840
Self Payment Gap: (What you need to pay out of pocket before you can access the "Above Threshold" benefit)
R10,225
R7,635
R2,880
"Above Threshold" benefit (ATB): Additional cover the scheme makes available to you, once you've paid the self payment gap.
Main= R9,200
Main+1= R16,380
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: Unlimited
R2,250 co-payment, unless PMB
No benefit for screening purposes
In and out of hospital
No limits or co-payments for PMB level care and/or for emergency
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:
R7,500 per family from day to day benefit
No limits or co-payments for PMB level care and/or for emergency
Transplants:
PMBs only
Dialysis:
PMBs only
Exclusions:
* 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: 40 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.
Claims are first paid Savings Account, then from Fund (AFB). When this is finished, member pays self-payment gap out of pocket. During this period, claims will accumulate to the annual threshold at the scheme rate. Once the annual threshold is reached, specific Above Threshold Benefits (ATB) will be available up to a limit of R8,280 per person and R14,676 per family
GP consultations:
From day-to-day benefit
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:
From day-to-day benefits, with a 30% co-payment if not referred by GP
Sublimit of R4,500 per family from above threshold benefit
Treatment required for PMB conditions is always paid paid by scheme, with no co-payment, if you follow the protocols. More info here
Pathology:
From day-to-day benefits
R3,500 per family limit from threshold benefit, combined with radiology
General radiology:
From day-to-day benefits
R3,500 per family limit from threshold benefit, combined with radiology
Specialised radiology:
MRI, CT and PET Scans: Unlimited
R2,250 co-payment
No benefit for screening purposes
In and out of hospital
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:
R7,500 per family from day to day benefit
General Appliances:
R17,900, from day-to-day benefit
1.1. Hearing Aids:
R17,700, from day-to-day benefit, every 3 years
1.2. Wheelchairs:
R4,600, from above Appliance limit
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.
Additional 38 conditions: from day-to-day benefit, up to R10,000 per person and R17,000 per family
Above threshold benefit is limited to R3,500 per family
You might be required to use specific pharmacies and be limited to specific medicines
Acute (presrcibed) medication:
From day-to-day benefit
R3,350 per family, when in threshold
Over-the-counter:
R200 per script
No sublimit in savings
R780 per person and R1,300 per family
Birth Control:
R2,950 per person, including devices
On Discharge:
7 days per admission
Biological:
R230,000 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
