Health Plans: Access Option

Access Option 2020

  • Unlimited hospitalisation In Network subject to sub-limits not being exceeded. Annual Member Savings Account:

       Member = 5 880

       Adult = 5 064
       Child = 1 142
       Out of hospital subject to sub limits and MSA*

  • Statutory Prescribed Minimum Benefits (PMBs).  Services rendered are payable at 100% of cost at designated service providers (DSPs) with no annual limit

  • 3 Month General Waiting Periods (Subject to the rights of interchangeability)

  • 12 Months condition specific waiting period for pre-existing conditions (Subject to the rights of interchangeability)

  • Claims received later than the last day of the 4th month in which the service was rendered will not be covered

  • 100% of Scheme rates are payable in RSA currency for emergencies when travelling abroad (subject to PMBs). This is also subject to completion of documentation prior to leaving RSA and requires approval by the Scheme

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Access Option: 2020 Benefits

IN-HOSPITAL BENEFITS

In-Hospital Benefits with No Annual Limit

Internal and External Prosthesis

  • 100% of Negotiated Tariff*
  • Limited to R30 883 per family per annum
  • Subject to PMB’s, pre-authorisation and protocols
Sub-Limits:
  • Limited to PMB conditions only
Back /Spinal instrumentation and disc prosthesis Joint Replacement (Hip, knee, shoulder and ankle)
  • Subject top overall limit and core procedure per beneficiary per annum unless PMB
Aphakic Lenses
  • R4 941 per lens
Cardiac Stents Subject to overall prosthesis limit and PMB protocols Maximum of 3 stents as per public hospital protocols for STEMI. No benefit for unstable angina or NSTEMI unless there is evidence of failed conservative medical treatment
  • Implantable Cardioverter Defibrillator (ICD); Subject to Scheme protocol and PMB for primary and secondary prevention
  • Cardiac Resynchronization Therapy (CRT) with Pacing Capabilities (CRT-D); Subject to Scheme protocol and PMB
Unlisted Prosthesis
  • Artificial Limbs and external prostheses including artificial eyes
  • Maximum R11 654 subject to overall limit
  • Subject to overall limits
Physiotherapy & Biokinetics
  • 100% of Scheme Tariff* Subject to PMB’s, treating doctor referral and pre‑authorisation by the auxiliary service provider during the admission period Limited to PMB conditions only
Dietician & Occupational Therapy
  • 100% of Scheme Tariff*
  • Subject to PMB’s, treating doctor referral and pre-authorisation by the auxiliary service provider during the admission period
  • Limited to PMB conditions only
Step Down Facilities (In lieu of hospitalisation)
  • 100% of Negotiated Tariff*
  • Subject to PMB’s, pre-authorisation and protocols
  • Limited to 14 days per beneficiary per annum
Private Nursing (In lieu of hospitalisation)
  • 100% of Negotiated Tariff*
  • Subject to PMB’s, pre-authorisation and protocols
  • Limited to 14 days per beneficiary per annum
Rehabilitation Facilities
  • 100% of Negotiated Tariff*
  • Limited to 14 days per beneficiary per annum
  • Subject to PMB’s, pre-authorisation and protocols
Circumcision
  • 100% of Scheme Tariff*
  • Subject to pre-authorisation
Hyperbaric Oxygen Therapy
  • 100% of Negotiated Tariff*
  • Subject to PMB’s, pre-authorisation and protocols
Negative Pressure Wound Therapy
  • 100% of Negotiated Tariff*
  • Subject to PMB conditions only
Medication for Age Related Macular Degeneration
  • 100% of Negotiated Tariff*
  • Subject to PMB’s, pre-authorisation and Scheme formulary* and protocol
Back Surgery
  • 100% of Scheme Tariff*
  • Subject to PMB’s, pre-authorisation and protocols
  • Back surgery is subject to adherence of the conservative back treatment protocol
  • Limited to PMB Conditions
Laparoscopic Hospitalisation and Associated Costs
  • Performed in a day hospital or as a day case
  • 100% of Scheme Tariff*
  • Subject to PMB’s, pre-authorisation and protocols
  • Laparoscopic Hospitalisation will attract a R5 592 co-payment
Exclusions for Hospital Admissions & Treatment Related to: (In conjunction with the Overall Scheme Exclusion List and subject to PMB’s)
  • Skin disorders
  • Arthroscopy
  • Bunionectomy
  • Removal of varicose veins
  • Refractive eye surgery, Aphakic lenses
  • Infertility treatment
  • Non-cancerous breast conditions

Deductible* Applied for In-Hospital Procedures R1 583 Deductible* – Except for PMB’s 1. Colonoscopy 2. Facet joint injections R3 165 Deductible* – Except for PMB’s 1. Gastroscopy 2. Cystoscopy 3. Hysteroscopy 4. Flexible sigmoidoscopy 5. Percutaneous radiofrequency ablations 6. Percutaneous rhizotomies R5 275 Deductible* – Except for PMB’s 1. Elective caesarean delivery 2. Joint replacements 3. Back surgery, including spinal fusion 4. Umbilical hernia repair 5. Hysterectomy 6. Functional nasal surgery Day Hospital Procedures Subject to Scheme Tariff* Procedures to be done at Designated Service Provider (DSP*) hospital network Subject to pre-authorisation Co-Payment applicable to defined conditions below
  1. Umbilical and Inguinal hernia repair
  2. Colonoscopy
  3. Cystoscopy
  4. Gastroscopy and Oesophagoscopy
  5. Hysteroscopy
  6. Grommets
  7. Termination of pregnancy
  8. Breast biopsy
  9. Cataracts
  10. Circumcision
  11. ERCP
  12. Haemorrhoidectomy
  13. Vasectomy
  14. Tubal Ligation
  15. Excision of extensive skin lesions or repair of wounds and skin grafts
  16. Dental procedures
  17. Repair nail bed & Removal of toenails
  18. Minor orthopaedic procedures such as tennis elbow, dupuytren’s contracture, trigger finger, ganglion, carpal tunnel syndrome
  19. Minor Gynaecological procedures – cone biopsy, colposcopy, D&C



In-Hospital Benefits that are Limited and Subject to Authorization

Subject to pre-authorisation, clinical protocols, formulary* and PMBs Note: All Admissions to hospitals and services listed below must be pre-authorised by the Scheme/preferred provider or within 48 hours in the case of an emergency Failure to comply with this rule will result in a levy of R1 000 per admission. Please note that treatment protocols apply Private Hospitals

  • 100% of DSP Tariff* and clinical protocols
  • Unlimited benefits for PMB conditions subject to pre-authorisation, use of a Designated Service Provider (DSP*) hospital network and prevailing clinical protocols and formulary*
  • Failure to comply utilising a DSP* provider will result in a 10% co-payment* per admission except for emergency admissions
Accommodation, Theatre Fees, Medicines, Intensive Care
  • Subject to Pre-authorisation and PMB’s
  • 100% of Scheme Tariff*
  • TTO benefit for 7 days
  • Subject to formulary*
Surgical Procedures Including GP and Specialist Consultations
  • Subject to Pre-authorisation and PMB’s
  • 100% of Scheme Tariff*
Diagnostic Investigations e.g. radiology, pathology, MRI/PET/CAT scans etc.
  • Subject to clinical protocols and PMB’s
  • 100% of Scheme Tariff*
  • Authorisation must be obtained prior to the examination or within 24 hours in case of emergency
  • Pathology Unlimited
  • Radiology Unlimited
  • Specialized Radiology subject to pre-authorization
Blood Transfusions 100% of Scheme Tariff* Subject to PMB Conditions only Oncology
  • Subject to PMB’s as prescribed
  • 100% of DSP Tariff*
  • Limited to PMB Conditions only
  • Based on DSP* ICON* Enhanced Protocols
  • Treatment subject to designated service provider guidelines and pre-authorisation
Psychiatric Treatment Including Clinical Psychology All treatment in hospital, including accommodation, medicines, materials, procedures, consultations, andpsychiatry/psychology therapy sessions
  • 100% of Scheme Tariff*
  • Subject to 21 Days per beneficiary or up to 15 out-patient contacts per annum
  • Subject to PMB’s, managed care protocols and pre-authorization by the Scheme
Drug and Alcohol Rehabilitation
  • PMB based on clinical protocols
  • 100% of Scheme Tariff*
  • Limited to R12 353 per family per annum
Organ Transplants
  • Subject to PMB’s and Pre-Authorisation
  • 100% of Scheme Tariff*
  • PMB based on Department of Health Protocols
  • Unlimited
Dental Hospitalisation
  • Subject to PMB conditions only
  • 100% of Scheme Tariff*
  • Subject to pre-authorization
Renal Dialysis
  • Subject to PMB’s and to pre-authorisation
  • 100% of Negotiated Tariff*
  • Unlimited benefits for PMB admissions and PMB level of Care
  • Subject to Treatment Protocols and formulary*
Sterilisation/Vasectomy
  • Subject to PMB Conditions only
  • 100% of Scheme Tariff*
  • Sterilisation limited to R16 000 per beneficiary per annum



MONTHLY PREMIUMS

Principal Member

Sole Member Monthly Premium: R 2,450



Member PLUS Adult

Principal Member: R 2,450 Adult Beneficiary: R 2,110 Total Monthly Premium: R 4,560



Member PLUS 1 Child

Principal Member: R5,438 Child Beneficiary: R931 Total Monthly Premium: R 6,369



Member PLUS Adult PLUS 1 Child

Principal member: R 2,450 Adult Beneficiary: R 2,110 Child Beneficiary: R 476 Total Contribution: R 5,036



Member PLUS Adult PLUS 2 Children

Principal Member: R 2,450 Adult Beneficiary: R 2,110 Child Beneciary 1: R 476 Child Beneficiary 2: R 476 Total Monthly Premium: R 5,512



Family (Member PLUS Adult PLUS 3 Children)

A maximum of three children will be charged: Princial Member: R 2,450 Adult Beneficiary: R 2,110 Child Beneficary 1: R 476 Child Beneficiary 2: R 476 Child Beneficiary 3: R 476 Total Monthly Premium: R 5,988



OUT-OF-HOSPITAL BENEFITS

Consultations and Diagnostic Benefits

Consultations (Including General Practitioners, Specialist and Outpatient Facilities)

  • 100% of Scheme Tariff*
  • Paid from MSA
  • 6 Additional GP Visits per Family per Annum once MSA is depleted
Specialist Consultations
  • Paid from MSA*
  • Specialist consultations requires GP referral or payment will be made at GP rates
Diagnostic Investigations
  • Subject to PMBs and protocols
  • 100% of DSP Tariff*
  • Paid from MSA
  • All specialised radiology subject to pre-authorisation
Pathology
  • Subject to PMBs
Radiology
  • Subject to PMBs
MRI/PET/CAT Scans
  • Limited to 2 scans per beneficiary per annum
  • In and out of hospital
  • Subject to pre-authorisation



Medicines and Injection Material

Acute Medicines (Including material)

  • 100% of Reference Price*
  • Paid from MSA*
  • Subject to Medicine formulary* and Protocols, Including Materials
  • Homeopathic Medication excluded
  • Acute Medication Obtained from Pharmacy: Subject to funds available in MSA
Pharmacy Advised Treatment (PAT) Over the counter medication
  • 100% of Reference Price*
  • Paid from MSA*
  • Consultation with Pharmacist, restricted to Schedule 0, 1 and 2 medicines
  • PAT subject to acute benefit limit
Contraceptive Benefit
  • 100% of Reference Price*
  • Paid from MSA
Chronic Medication Subject to registration, pre-authorisation, treatment protocols and medicine formulary* with the Scheme’s preferred provider (DSP*) PMB Chronic Disease List Medicines
  • 100% of Reference Price Cost Unlimited
  • Chronic Medication to be Obtained from Preferred Provider Network
  • Subject to renewal of prescription every six months
  • Paid from Risk Pool



Optical Benefits

Spectacle Lenses: In Network

  • 100% of DSP Tariff*
  • R185 per lens – clear single vision, or
  • R420 per lens – clear bifocal vision, or
  • R745 per lens – base multifocal
  • Fixed tints up to 35%
  • No benefit for contact lenses if spectacles purchased
  • Benefit applicable to members who utilize the Scheme’s Preferred Provider
  • Network Optometrists only
  • Limited to one pair of spectacles per beneficiary every 24 months
Contact Lenses: In Network
  • 100% of DSP Tariff*
  • Paid from Risk Pool
  • R950 per beneficiary every 24 months
  • No claim for specialists if contact lenses purchased
  • Subject to clinical protocol
Frames/Lens
  • 100% of DSP Tariff*
  • Paid from Risk Pool
  • R548 per frame
  • No benefit per frame if contact lenses are purchased
  • One claim per beneficiary every 24 months
Eye Tests: In Network
  • 100% of DSP Tariff*
  • Paid from Risk Pool
  • One comprehensive consultation per beneficiary every 24 months
ALL OPTICAL BENEFITS:
  • Contact the Scheme’s preferred provider network for availability and locality of network optometrists
  • Benefits applicable to members who utilise the Scheme’s preferred provider network optometrists only



Dental Benefits

Conservative Dentistry (Dentist and Dental Therapist)

  • Conscious sedation: Extensive dental treatment (more than 4 fillings or extractions) subject to dental treatment protocols and preauthorisation
  • 100% of Scheme Tariff*
  • Paid from Risk Pool
  • Consultations, Fillings, Extractions, Two (2) root canal treatments per family per annum
  • Preventative scale and polish
  • Fluoride treatment limited to beneficiaries below the age of
  • 12 years
  • Conscious sedation for children up to the age of 12 years
  • Root Canal treatment included in conservative dentistry
  • X-rays (limited to intra-oral)
  • Dental protocols apply and pre-authorisation required for extensive treatment plans
  • Quantity Limitations Apply
  • Contracted Network Provider Only
Advanced Dentistry
  • Non-PMB’s Paid from MSA*
  • All clinically valid specialised dental treatment covered from MSA* including 1 set of Acrylic (plastic) denture per beneficiary every 4 years.
  • Cover available for realigning and repairing every 12 months
  • Including Repairs of Dentures
  • Subject to PMB conditions only
Maxillo-Facial and Oral, Including Dental Surgery (Consultations, surgical procedures and operations)
  • Subject to PMB conditions only



Auxiliary Benefits

Alternative Services (Homeopathy, naturopathy, chiropractor and podiatry)

  • 100% of Scheme Tariff*
  • Non-PMB’s paid from MSA*
  • Appropriate referral by GP/Specialist, failing to do so will result in no payment
  • Subject to PMB’s and Protocols
Remedial and Other Therapies (Audiology, speech therapy, dieticians, hearing aid acousticians, occupational therapy, orthotics, social workers and speech therapy)
  • 100% of Scheme Tariff*
  • Subject to PMB conditions and clinical protocols
  • Non-PMBs from MSA
  • Appropriate referral by GP/Specialist
Physiotherapy Out Of Hospital (Biokinetics & Physiotherapy)
  • 100% of Scheme Tariff*
  • R2 727 per beneficiary limited to R4 370 per family
  • per annum
Appliances (Hearing aids, wheelchairs, calipers, etc.)
  • Subject to pre-authorisation
  • 100% of Negotiated Tariff*
  • Limited to R6 526 per family per annum
  • Paid from Risk Pool subject to sub-limit
  • In & Out of Hospital - PMBs only
    • Blood Pressure Monitors Subject to a sub-limit of R550 for ben eficiaries registered for Hypertension



Other Benefits

Air/Road Ambulance and Emergency Services (24-hour access to call centre, including telephonic nurse advice line)

  • 100% of Scheme Tariff
  • The Schemes preferred provider must be contacted should you require an Ambulance – failure to adhere to this could result in you being held liable for costs incurred
Emergency: Subject to pre-authorisation within 72 hours after the emergency. Inter-hospital transfers must be done by preferred provider only
  • Emergency response by road or air to scene of incident and transfer from scene, to closest, most appropriate facility
  • Escort return of stranded minors can be arranged
Non-emergency: Subject to pre-authorisation beforehand
  • Facilitation of medically justified inter-facility transfers
  • Medical repatriation
Psychology and Psychiatry Treatment
  • Subject to PMB’s and referral from GP or Specialist, failure to do so will result in no payment
  • Subject to confirmed diagnosis, treatment plan and managed care protocols
  • 100% of Scheme Tariff*
  • Subject to PMB conditions only
  • Non-PMBs paid from MSA
Infertility
  • Subject to PMB conditions only
  • Non-PMBs paid from MSA
  • 100% of Scheme Tariff*
Hospice and Private Nursing
  • Subject to PMBs, pre-authorisation and protocols
  • 100% of Negotiated Tariff*
  • Subject to PMB conditions only
  • Non-PMBs paid from MSA



MATERNITY BENEFITS

Maternity Visit/s

Additional 7 GP consultations and 2 specialist consultations per pregnancy at GP or Specialist (Once these limits have been reached further ante-natal consultations will be paid from the day-to-day benefit)



Maternity Ultrasound/s

Limited to 2 x 2D ultrasounds per pregnancy for In and Out of Hospital.



Home Delivery

  • Limited to R4 661 / pregnancy.
  • 100% of Negotiated Tariff



Hospital Confinement

  • NVD – Limited to 2 days
  • Caesarean – Limited to 3 Days



Immunisation Benefit

Immunisation as per the Immunisation schedule by the Department of Health up to 12 months of age



Antenatal Classes

No Benefit



WELLNESS BENEFITS

Papsmear

Female beneficiaries over 18 years



Mammogram

Female beneficiaries over 40 years



HPV Vaccination

All beneficiaries between 9 and 12 years



Prostate Specific Antigen (PSA

Male beneficiaries over 40 years



HIV Testing Benefit

Free HIV Test per beneficiary per annum





Cholesterol Test

All beneficiaries over 20 years



Blood Sugar Test

All beneficiaries over 15 ye



Blood Pressure Check

All beneficiaries Reimbursement of Blood Pressure Monitors on all Option



Flu Vaccination

All beneciaries



Pneumococcal Vaccinati

One free Pneumococcal Vaccination per beneficiary over 65 years per annum



CHRONIC BENEFITS

Chronic Conditions Covered

1. Addison’s Disease 2. Asthma 3. Bipolar Mood Disorder 4. Bronchiectasis 5. Cardiac Failure 6. Cardiomyopathy 7. Chronic Obstructive Pulmonary Disease 8. Chronic Renal Disease 9. Coronary Artery Disease 10. Crohn’s Disease 11. Diabetes Insipidus 12. Diabetes Type 1 13. Diabetes Type 2 14. Dysrhythmias 15. Epilepsy 16. Glaucoma 17. Haemophilia 18. HIV/AIDS 19. Hyperlipidaemia 20. Hypertension 21. Hypothyroidism 22. Multiple Sclerosis 23. Parkinson’s Disease 24. Rheumatoid Arthritis 25. Schizophrenia 26. Systemic Lupus Erythematosus 27. Ulcerative Colitis



Accessing Your Chronic Medication

Register to access your Chronic Medication on the Chronic line by calling 0860 00 00 48 or by sending an email to hosmedcmm@hosmed.co.za or at your Pharmacy



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