Self Payment Gap: (What you need to pay out of pocket before you can access the "Above Threshold" benefit)
R6,544
R3,768
R1,136
"Above Threshold" benefit (ATB): Additional cover the scheme makes available to you, once you've paid the self payment gap.
Unlimited
Unlimited
Unlimited
Children Rates:
Under 27yrs, provided they are financially dependant, unmarried and don't earn more than the maximum social pension
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
Single hip and knee replacement: no co-payment if contracted
Other joint replacements: R5,440 co-payment
Spinal Surgery: R7,130 co-payment
* 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 and CT Scan: R2,810 co-payment, in and out-of hospital
No limits or co-payments for PMB level care and/or for emergency
Supplementary Services: (Physio, etc)
100% scheme rate
Dietetics, occupational therapy and speech therapy: from day-to-day benefit, R19,400 per family. Does not accumulate to Threshold, but does pay from it.
No limits or co-payments for PMB level care and/or for emergency
Transplants:
R624,000
Corneal graft: R36,300 per person
Dialysis:
R624,000
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:
Nursing services: Unlimited
Sub acute facilities, physical rehab: Unlimited
Terminal care: R34,500 per person
Casualty:
Emergency treatment, like stitches: R660 co-payment, unless PMB
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.
This plan also has a savings account and a self payment gap that accumulates to a "threshold". After the threshold is reached, Fedhealth will pay some day-to-day claims.
There is a 10% co-payment for all benefits paid from Threshold.
GP consultations:
Network GP: From day-to-day benefit, then paid by scheme
Non-Network GP: From day-to-day benefit. Does not accumulate to Threshold, but does pay from it.
Treatment required for PMB conditions is always paid paid by scheme, with no co-payment, if you follow the protocols. More info here
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.
Overall benefit: R7,890 per person and R14,500 per family. Thereafter, the 27 PMB conditions only
You might be required to use specific pharmacies and be limited to specific medicines
Acute (presrcibed) medication:
From day-to-day benefits
R7,940 per person and R14,700 per family, before and after Threshold
Over-the-counter:
From day-to-day benefits
Does not accumulate or pay from Threshold
Birth Control:
Oral, patches, contraceptive rings, certain injectables, and IUDs (including Mirena): Paid by scheme, if prescribed
On Discharge:
7 days
Biological:
R194,600, per family
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
