Health Plans: Value Core Option

Value Core 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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Value Core Option: 2020 Benefits

IN-HOSPITAL BENEFITS

In-Hospital Benefits with No Annual Limit

Internal and External Prosthesis

  • 100% of Negotiated Tariff*
  • Limited to R47 990 per family per annum
  • Subject to PMB’s, pre-authorisation and protocols
Sub-Limits: Back /Spinal instrumentation and disc prosthesis
  • Limited to a maximum of 2 levels unless clinically motivated and approved or within PMB protocols
  • R29 304 per level subject to overall limit not being exceeded
  • Maximum 1 event per beneficiary per annum
Joint Replacement (Hip, knee, shoulder and ankle)
  • Limited to one event per annum, unless sepsis or trauma
  • R40 987 per annum - Subject to the overall limit and maximum of one procedure per beneficiary per annum. Excludes cement
Aphakic Lenses
  • Subject to protocol and PMB’s
  • R5 707 per lens
Cardiac Stents
  • 1 per lesion – maximum 3 lesions
  • Bare metal stents: R13 984 per stent
  • Drug eluting stents: R19 811 per stent
The following is subject to the overall prosthesis benefit:
  • Cardiac valves, aortic stent grafts, peripheral arterial stents grafts, single/dual pacemaker
  • Cardiac resynchronization devices (CRT), implantable cardioverter defibrillators (ICD) with pacing capabilities (CRT-D) - 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
  • Internal sphincters and stimulators
  • Neurostimulators/internal nerve stimulator for Parkinson‘s Disease - Subject to clinical protocol and medical management being exhausted. Subject to overall limit
  • Cochlear implants - Subject to overall limit for device
  • Insulin pumps and monthly materials - Children under 7 years of age only. Subject to clinical protocols and overall limit
Unlisted Prosthesis
  • Artificial Limbs and external prostheses including artificial eyes
  • Maximum R13 984 subject to overall 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
  • Subject to Scheme protocols
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
  • Subject to Scheme protocols
Step Down Facilities (In lieu of hospitalisation)
  • 100% of Negotiated Tariff*
  • Subject to PMB’s, pre-authorisation and protocols
  • Limited to 1 4 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 In and out of hospital
  • 100% of Scheme Tariff*
  • In and Out of hospital
  • Subject to pre-authorisation
Hyperbaric Oxygen Therapy
  • 100% of Negotiated Tariff*
  • Limited to R42 536 per family per annum
  • Subject to PMB’s, pre-authorisation and protocols
Negative Pressure Wound Therapy
  • 100% of Negotiated Tariff*
  • Limited to R26 803 per family per annum
  • Subject to PMB’s, pre-authorisation and protocols
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
  • R5 000 co-payment* applicable for all non-PMB spinal surgery
Stereotactic Radio-Surgery
  • 100% of Scheme Tariff*
  • Subject to PMB’s, pre-authorisation and protocols
  • Only covered for primary central nervous system tumours
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* except for the following circumstances where no co-payment* will apply:
    • Purely diagnostic laparoscopy
    • Aspiration/excision ovarian cyst
    • Lap-appendicectomy
    • Repair of recurrent or bilateral inguinal hernias
Exclusions for Hospital Admissions & Treatment Related to: (In conjunction with the Overall Scheme Exclusion List and subject to PMB’s) Refer to Scheme Exclusion list Deductible* Applied for In-Hospital Procedures Deductable of R5 000 will apply to the below procedures in hospital except for PMB Conditions:
  • Joint Replacement
  • Umbilical Hernia Repair
  • Hysterectomy
  • Functional Nasal Surgery
  • Elective caesarean section
Day Hospital Procedures Subject to Scheme Tariff*
  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 Scheme Tariff*
  • Unlimited subject to pre-authorisation, use of the Netcare Hospital Group (DSP*), clinical protocols and formulary*
  • Subject to sub-limits not being exceeded
  • Failure to comply utilising a DSP* provider will result in non-payment
  • In case of PMB voluntary use of non-DSP will result in a 10% co-payment* per admission except for emergency admissions clinical protocols and formulary*
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 Pre-authorisation and PMB’s
  • 100% of Scheme Tariff*
  • Authorisation must be obtained prior to the examination or within
  • 24 hours in case of emergency
  • All specialised radiology subject to pre-authorisation
Blood Transfusions 100% of Scheme Tariff* Oncology
  • Subject to PMB’s as prescribed
  • 100% of DSP Tariff*
  • Limited to R287 842 per beneficiary per annum
  • 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*
  • Subject to 21 Days per beneficiary or up to 15 out-patient contacts per annum (Subject to PMB’s)
  • Non PMB’s – 14 days per family subject to a limit of R20 511
  • Payment up to 3 days for Psychologist charging therapy sessions with Psychiatrist in the same admission, thereafter pre-authorisation required with treatment plan
Drug and Alcohol Rehabilitation
  • Subject to PMB’s, Managed care protocols and pre-authorisation
  • 100% of Scheme Tariff*
  • Limited to R19 345 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 pre-authorisation, and treatment protocols and PMB’s
  • 100% of Scheme Tariff*
  • Anaesthetist and Hospital cost is payable from hospital benefit
  • Provider fee subject to available Advanced Dentistry Benefit
  • Benefit is payable from hospital benefit only in the following cases:
    • Extensive conservative treatment for children under 7 years of age and more than 3 teeth involved
    • Removal of symptomatic impacted wisdom teeth if pre-authorised as a day case only
Maxillo-Facial and Oral Surgery
  • 100% of Scheme Tariff*
  • Maxillo-facial and oral surgery limited to symptomatic wisdom
  • teeth and surgical exposures
  • Anaesthetist and Hospital cost is payable from hospitalisation:
  • Removal of symptomatic impacted wisdom teeth if pre-authorised
  • as a day case only
  • All other procedures subject to PMB only
Renal Dialysis
  • Subject to PMB’s and to pre-authorisation
  • 100% of Negotiated Tariff*
  • Unlimited benefits for PMB admissions
  • Subject to Treatment Protocols and formulary*
Sterilisation/Vasectomy
  • Subject to pre-authorisation
  • 100% of Scheme Tariff*
  • Sterilisation limited to R16 000 per beneficiary per annum



MONTHLY PREMIUMS

Principal Member

Sole Member Monthly Premium: R3,214



Member PLUS Adult

Principal Member: R3,214 Adult Beneficiary: R2,350 Total Monthly Premium: R5,564



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: R3,214 Adult Beneficiary: R2,350 Child Beneficiary: R547 Total Contribution: R6,111



Member PLUS Adult PLUS 2 Children

Principal Member: R 3,214 Adult Beneficiary: R 2,350 Child Beneciary 1: R 547 Child Beneficiary 2: R 547 Total Monthly Premium: R 6,658



Family (Member PLUS Adult PLUS 3 Children)

A maximum of three children will be charged: Princial Member: R 3,214 Adult Beneficiary: R 2,350 Child Beneficary 1: R 547 Child Beneficiary 2: R 547 Child Beneficiary 3: R 547 Total Monthly Premium: R 7,205



OUT-OF-HOSPITAL BENEFITS

Consultations and Diagnostic Benefits

Consultations (Including General Practitioners, Specialist and Outpatient Facilities)

  • 100% of Scheme Tariff*
  • 10 Visits per Beneficiary limited to 20 Visits per Family per Annum
Specialist Consultations Member: 3 Visits, Member + 1 = 5 Visits, Member + 2 + = 7 Visits Specialist consultations require GP referral or payment will made at GP rates, except for: • Paediatricians • Gynaecologists Diagnostic Investigations
  • Subject to PMBs and protocols
  • 100% of Scheme Tariff*
  • All specialised radiology subject to pre-authorisation
Pathology
  • Limited to R2 779 per beneficiary per annum
Radiology
  • Limited to R2 162 per beneficiary per annum
MRI/PET/CAT Scans
  • Limited to 2 scans per beneficiary per annum
  • Subject to pre-authorisation



Medicines and Injection Material

Acute Medicines (Including material and homeopathic medicine)

  • 100% of Reference Price
  • Limited to R5 442 per beneficiary and R11 046 per family per annum
  • Subject to Medicine formulary* and Protocols, Including Materials and
  • Homeopathic Medicine
Pharmacy Advised Treatment (PAT) Over the counter medication
  • 100% of Reference Price*
  • Limited to R2 021 per family per annum
  • Maximum R156 per script
  • Included in Acute Medication Limit above
  • Consultation with Pharmacist, restricted to Schedule 0, 1 and 2 medicines
  • PAT subject to acute benefit limit
Contraceptive Benefit
  • Subject to oral, injectable and patch contraceptives only
  • 100% of Reference Price*
  • Limited to R1 399 per family per annum. Subject to oral, injectable and patch contraceptives formulary
Chronic Medication Subject to registration, pre-authorisation, treatment protocols and medicine formulary* with the Scheme’s preferred provider (DSP*) Other Chronic (Non-CDL) Medicines
  • 100% of Reference Price*
  • R6 917 per beneficiary Limited to R13 960 per family per annum
  • PMB’s subject to registration and pre-authorisation with the Schemes preferred provider
  • Chronic Medication to be Obtained from Preferred Provider Network
  • Subject to renewal of prescription every six months
  • Subject to pre-authorisation, treatment protocols and medicine formulary*
  • Non-formulary* products will incur a 30% co-payment* where these are obtained voluntarily by beneficiaries
PMB Chronic Disease List Medicines
  • 100% of Reference Price Cost Unlimited
  • Benefit initially payable from limit above
  • Non-formulary* products will incur a 30% co-payment* where these are obtained voluntarily by beneficiaries
  • Benefit Initially payable from chronic medicine limit above
  • Chronic Medication to be Obtained from Preferred Provider Network - Subject to renewal of prescription every six months
  • PMB’s subject to registration and pre-authorisation with the Schemes preferred provider - Subject to pre-authorisation, treatment protocols and medicine formulary*



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
  • 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*
  • R1 810 per beneficiary every 24 months
  • No benefit for spectacles if contact lenses purchased
  • Subject to clinical protocol
  • Benefit applicable to members who utilize the Scheme’s preferred provider network optometrist only
Frames/Lens
  • 100% of DSP Tariff*
  • R795 per beneficiary
  • Enhancements: In Network
  • No benefit per frame if contact lenses are purchased
  • Benefit applicable to members who utilize the Scheme’s preferred provider network optometrist only
  • One claim per beneficiary every 24 months
Eye Tests: In Network
  • 100% of DSP Tariff*
  • Benefit applicable to members who utilize the Scheme’s preferred provider
  • network optometrist only
  • One claim 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*
  • Unlimited
  • Consultations, Fillings, Extractions, Root canal treatment two (2) RCT 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 intra-oral covered
  • Panoramic Radiographs limited to 1 per beneficiary every 24 months
  • Subject to dental treatment protocols and pre-authorisation for extensive treatment
Advanced Dentistry (e.g. Crowns & Bridgework, Dentures, Root Canal Treatments, Orthodontics, removal of impacted wisdom teeth and Non- Periodontics)
  • Subject to pre-authorisation by the Scheme and treatment protocols
  • Failure to obtain pre-authorisation will result in no payment
  • 100% of Scheme Tariff*
  • R4 452 per beneficiary limited to R6 363 per family per annum
  • Crowns and Bridges, Impacted wisdoms and Orthodontics
Dental Implants
  • R15 000 per family once every five years
Partial Metal Frame Dentures
  • Subject to the above available limit
  • Limited to one (1) set per beneficiary every 5 years
Acrylic (Plastic) Dentures
  • Subject to advanced dentistry limit
  • Limited to 1 per beneficiary every 4 years
  • Contracted Network Provider Only
Maxillo-Facial and Oral, Including Dental Surgery (Consultations, surgical procedures and operations)
  • Subject to PMBs, pre-authorisation and protocols
  • 100% of Scheme Tariff*
  • (included in advanced dentistry limit)
  • Benefit is payable from hospitalisation in cases of accidents, injury, congenital abnormalities and oncology related procedures only



Auxiliary Benefits

Alternative Services (Homeopathy, naturopathy, chiropractor and podiatry)

  • 100% of Scheme Tariff*
  • Collectively limited to R3 753 per family per annum
  • Medicine dispensed limited to Acute Medication Limit
Remedial and Other Therapies (Audiology, speech therapy, dieticians, hearing aid acousticians, occupational therapy, orthotics, social workers and speech therapy)
  • 100% of Scheme Tariff*
  • Collectively limited to R3 625 per family per annum
Physiotherapy Out Of Hospital (Biokinetics & Physiotherapy)
  • 100% of Scheme Tariff*
  • R1 701 per beneficiary limited to R2 820 per family
  • per annum
Appliances (Hearing aids, wheelchairs, calipers, etc.)
  • Subject to pre-authorisation
  • 100% of Negotiated Tariff*
  • Limited to R14 007 per family per annum
  • Stoma Care – Subject to a sub limit of R7 225 per family per annum
    • Wheelchairs – one claim per Beneficiary every 36 months subject to pre-authorisation.
    • Hearing aids – one claim per beneficiary every 24 months subject to pre-authorisation
    • 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*
  • R2 948 per beneficiary, Limited to R7 412 per Family
Infertility
  • Subject to PMB’s and State/Public Facilities protocals
  • 100% of Scheme Tariff*
Hospice and Private Nursing
  • Subject to PMBs, pre-authorisation and protocols
  • 100% of Negotiated Tariff*
  • Subject to combined limit of a maximum period of 14 days per annum, except for PMBs



MATERNITY BENEFITS

Maternity Visit/s

Additional 6 GP consultations and 3 specialist consultations per pregnancy (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 R5 826 / 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