The scheme might still cover some or all day-to-day claims. See below, and see benefits.
Children Rates:
Pay for all
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
Assume scheme pays all these costs, unless otherwise stated
non-Network Specialists:
200% scheme rate
Scheme rate is set by Cape Medical
network Specialists:
200% scheme rate
non-Network GPs:
200% scheme rate
network GPs:
200% scheme rate
Hospital Choice:
Any hospital
Day Hospitals:
Use of day hospitals is not required
Penalty for using other hospital:
n/a
You don't pay a penalty if admission was unavoidable due an emergency
Other Co-payments:
Laparoscopic and Endoscopic procedures: R1,000 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:
Angiograms, CT scans, duplex doppler scans, interventional radiology, MRI, and nuclear medical investigations: R14,732 per person, with R1,500 co-payment, in and out of hospital
No limits or co-payments for PMB level care and/or for emergency
Supplementary Services: (Physio, etc)
200% scheme rate
No limits or co-payments for PMB level care and/or for emergency
Transplants:
PMBs only
Dialysis:
PMBs only
Exclusions:
Pathology: If you don't use Lancet or Pathcare, only the first 24 hours of tests after admission are covered by scheme
* 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:
Step-down facilities, hospices, registered nurses and rehabilitation centres: 15 days per person
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.
Consult and procedures: 1 per person, 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:
Paediatric consults: R2,818 per child, paid by scheme
Specialists consultations:
No cover
Treatment required for PMB conditions is always paid paid by scheme, with no co-payment, if you follow the protocols. More info here
Pathology:
Covered in full by scheme if you use Lancet or Pathcare
General radiology:
No cover
Specialised radiology:
Angiograms, CT scans, duplex doppler scans, interventional radiology, MRI, and nuclear medical investigations: R14,732 per person, with R1,500 co-payment, 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)
No cover
General Appliances:
In-hospital: Covered at scheme rate. Limits apply.
External: No benefit
1.1. Hearing Aids:
No benefit
1.2. Wheelchairs:
No benefit
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 cover
Over-the-counter:
Birth Control:
No benefit
On Discharge:
No benefit
Biological:
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
