Health Plans: Essential Option

Essential Option 2020

  • Annual limits are limited to PMB conditions only for in and out of hospital benefits and are subject to sub-limits not being exceeded

  • Prorated benefits are applicable if you join after the 1st of January of a benefit year

  • 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

  • The Essential Package does not cover emergencies when travelling abroad

Download shows Benefits across all Options

Essential Option: 2020 Benefits

IN-HOSPITAL BENEFITS

In-Hospital Benefits with No Annual Limit


Internal and External Prosthesis

  • 100% of Negotiated Tariff*
  • Limited to R19 641 per family per annum
Sub-Limits: Back /Spinal instrumentation and disc prosthesis
  • Limited to PMB conditions only
Joint Replacement (Hip, knee, shoulder and ankle)
  • Excluded unless PMB. Prosthesis limited to equivalent available in the state.
Aphakic Lenses
  • Subject to PMB
Cardiac Stents Subject to PMB only. 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. Subject to overall prosthesis limit and PMB protocols
  • 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 R9 323 subject to overall prosthesis limit
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*
  • Limited to PMB conditions only
Private Nursing (In lieu of hospitalisation)
  • 100% of Negotiated Tariff*
  • Limited to PMB conditions only
Rehabilitation Facilities
  • 100% of Negotiated Tariff*
  • Limited to PMB conditions only
Circumcision In and out of hospital
  • 100% of Scheme Tariff*
  • Limited to PMB conditions only
Hyperbaric Oxygen Therapy
  • 100% of Negotiated Tariff*
  • Limited to PMB conditions only as per public hospital protocols
Negative Pressure Wound Therapy
  • 100% of Negotiated Tariff*
  • Limited to PMB conditions only
Medication for Age Related Macular Degeneration
  • Limited to PMB conditions only
Back Surgery
  • Back surgery is subject to conservative back treatment
  • Limited to PMB conditions only
Exclusions for Hospital Admissions & Treatment Related to: Refer to Scheme Exclusion list Day Hospital Procedures Procedures to be done at Designtaed Service Provider (DSP) hospital network Subject top pre-authorization Subject to Scheme Tariff* Subject to PMB conditions only:
  1. Biopsy
  2. Breast Biopsy
  3. Cataract
  4. Colonoscopy
  5. Cone Biopsy/ Colposcopy
  6. Cystoscopy
  7. ERCP
  8. Excision of Extensive Skin lesions /Repair/Skin Graft
  9. Gastroscopy or Colonoscopy or Oesophagoscopy
  10. Haemorrhoidectomy
  11. Hysteroscopy, D&C, Minor Gynaecological Procedures
  12. Grommets
  13. Repair of Wounds
  14. Termination of Pregnancy
  15. Umbilical and Inguinal Herniaoscopy, 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 Subject to 100% of DSP Tariff* and clinical protocols Limited to PMB conditions only

  • Unlimited benefits for PMB conditions subject to preauthorisation and 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
  • 100% of Scheme Tariff*
  • TTO benefit for 7 days
  • Subject to formulary*
  • Limited to PMB conditions only
Surgical Procedures Including GP and Specialist Consultations
  • Limited to PMB conditions only
  • 100% of Scheme Tariff*
Diagnostic Investigations e.g. radiology, pathology, MRI/PET/CAT scans etc.
  • 100% of Scheme Tariff*
  • Subject to Clinical protocols and PMB’s
  • Limited to PMB conditions only
  • Combined limited of R6 177 per beneficiary per annum
  • Pathology and Radiology: Network Provider Only. Limited to PMB conditions only
  • Specialised Radiology: MRI/PET/CT Scans Limited to 2 per beneficiary per annum for In and Out Hospital
  • Limited to PMB conditions only
Blood Transfusions 100% of Scheme Tariff* Subject to PMB conditions only Oncology
  • Limited to PMB conditions
  • 100% of DSP Tariff*
  • 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
  • Subject to PMB’s, managed care protocols and pre-authorisation by the Scheme
  • 100% of Scheme Tariff*
  • Limited to PMB conditions only
  • Subject to 21 Days per beneficiary or up to 15 out-patient contacts per annum (Subject to PMB’s)
Drug and Alcohol Rehabilitation
  • Subject to PMB’s and pre-authorisation
  • Limited to PMB conditions only
  • 100% of Scheme Tariff*
  • PMB based on Department of Health Protocols
Organ Transplants
  • Subject to PMB’s and Pre-Authorisation
  • 100% of Scheme Tariff*
  • PMB based on Department of Health Protocols
  • Limited to PMB conditions only
Dental Hospitalisation
  • 100% of Scheme Tariff*
  • Limited to PMB conditions only
  • Subject to pre-authorisation
Renal Dialysis
  • Subject to PMB’s and to pre-authorisation
  • 100% of Negotiated Tariff*
  • Limited to PMB conditions only
  • Unlimited benefits for PMB admissions and PMB level of care
  • Subject to Treatment Protocols and formulary*
Sterilisation/Vasectomy
  • 100% of Scheme Tariff*
  • Limited to PMB conditions only





MONTHLY PREMIUMS

Principal Member


Sole Member Monthly Premium: R 2,131




Member PLUS Adult


Principal Member: R 2,131 Adult Beneficiary: R 2,027 Total Monthly Premium: R 4,158




Member PLUS 1 Child


Principal Member: R 2,131 Child Beneficiary: R 825 Total Monthly Premium: R 2,956




Member PLUS Adult PLUS 1 Child


Principal member: R 2,131 Adult Beneficiary: R 2,027 Child Beneficiary: R 825 Total Contribution: R 4,983




Member PLUS Adult PLUS 2 Children


Principal Member: R 2,131 Adult Beneficiary: R 2,027 Child Beneciary 1: R 825 Child Beneficiary 2: R 825 Total Monthly Premium: R 5,808




Family (Member PLUS Adult PLUS 3 Children)


A maximum of three children will be charged: Princial Member: R 2,131 Adult Beneficiary: R 2,027 Child Beneficary 1: R 825 Child Beneficiary 2: R 825 Child Beneficiary 3: R 825 Total Monthly Premium: R 6,633





OUT-OF-HOSPITAL BENEFITS

Consultations and Diagnostic Benefits


Consultations (Including General Practitioners, Specialist and Outpatient Facilities)

  • 100% of DSP Tariff*
  • Unlimited visits & acute medication from any GP within the DSP* Network at 100% of DSP* Tariff*
Specialist Consultations
  • 100% of Scheme Tariff*
  • Limited to 3 Visits per family per annum only on referral from DSP* GP.
  • Subject to pre-authorisation
  • Limited to PMB conditions only
Diagnostic Investigations
  • Subject to PMBs and protocols
  • Pathology: Limited to R863 per beneficiary per annum Network Provider
  • Only Limited to PMB conditions only
  • Radiology: Limited to R863 per beneficiary per annum Referral by Network Provider Only Limited to PMB conditions only
Specialized Radiology: MRI/PET/CAT Scans
  • Limited to 2 scans per beneficiary per annum
  • Subject to pre-authorisation
  • Referral by Network Provider only
  • Limited to PMB conditions only




Medicines and Injection Material


Acute Medicines (Including material and homeopathic medicine)

  • 100% of Reference Price*
  • DSP* GP
  • Unlimited Acute medication dispensed by the DSP* GP
  • Subject to Medicine formulary* and Protocols, Including Materials.
  • Homeopathic Medication excluded
  • Acute Medication Obtained from Pharmacy: R1 266 per beneficiary limited to R3 534 per family per annum
Pharmacy Advised Treatment (PAT) Over the counter medication
  • 100% of Reference Price*
  • Limited to R646 per family per annum
  • Maximum R95 per script
  • Consultation with Pharmacist, restricted to Schedule 0, 1 and 2 medicines
  • PAT subject to acute benefit limit
Contraceptive Benefit
  • 100% of Reference Price*
  • Limited to R64 per beneficiary per month, subject to R767 per family per annum.
  • Subject to oral and injectable contraceptives only
  • Subject to the contraceptive formulary*
Chronic Medication Subject to registration, pre-authorisation, treatment protocols and medicine formulary* with the Scheme’s preferred provider (DSP*) GP PMB Chronic Disease List Medicines
  • 100% of Reference Price Cost Unlimited
  • Provider Network Only




Optical Benefits


Spectacle Lenses: In Network

  • 100% of DSP Tariff*
  • R185 per lens – clear single vision, or
  • R420 per lens – clear bifocal vision, or
  • R420 per lens – base multifocal
  • No Benefit for Fixed Tints No benefit for contact lenses if spectacles purchased Limited to one pair of spectacles per beneficiary every 24 months
Contact Lenses: In Network
  • 100% of DSP Tariff*
  • R615 per beneficiary every 24 months
  • No benefit for spectacles if contact lenses purchased Provider Network Only
  • Subject to clinical protocol
Frames/Lens
  • 100% of DSP Tariff*
  • R300 per beneficiary
  • No benefit per frame if contact lenses are purchased
  • One claim per beneficiary every 24 months
Eye Tests: In Network
  • 100% of DSP Tariff*
  • 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* Consultations, Fillings, Extractions
  • 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
  • Limited to PMB conditions only
  • Acrylic (Plastic) Dentures
  • 1 set of Acrylic/plastic dentures per beneficiary every 4 years.
  • Cover available for realigning and repairing every 12 months Including Repairs of Dentures
Maxillo-Facial and Oral, Including Dental Surgery (Consultations, surgical procedures and operations)
  • Limited to PMB conditions only




Auxiliary Benefits


Remedial and Other Therapies (Audiology, speech therapy, dieticians, hearing aid acousticians, occupational therapy, orthotics, social workers and speech therapy)

  • Limited to PMB conditions only
Physiotherapy Out Of Hospital (Biokinetics & Physiotherapy)
  • Limited to PMB conditions only and clinical protocols
  • Cardiac and Respiratory conditions: Subject to provision of treatment plan and therapy goals.
  • Maximum of 6 sessions per beneficiary, thereafter subject to progress report and evidence of response.
  • Treatment for Back pain: Subject to treatment plan for back pain
Appliances (Hearing aids, wheelchairs, calipers, etc.)
  • Subject to pre-authorisation
  • 100% of Negotiated Tariff*
  • Limited to R2 914 per family per annum In and Out of Hospital Limited to PMB conditions only
    • Blood Pressure Monitors Subject to a sub-limit of R550 for beneficiaries 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
  • Limited to PMB conditions only
Infertility
  • Limited to PMB conditions only ast State/Public facilities
Hospice and Private Nursing
  • Subject to PMBs, pre-authorisation and protocols
  • 100% of Negotiated Tariff*
  • Limited to PMB conditions only





MATERNITY BENEFITS

Maternity Visit/s


  • 100% of Scheme Tariff*
  • Subject to DSP*
  • GP and Specialist consultation limit as per Consultations




Maternity Ultrasound/s


Limited to 2 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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3 Victoria Link, Route 21 Corporate Park, Irene, 0178

0861 hosmed (467 633)

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