Health Plans: Value Option

Value Option 2020

  • There is no overall annual limit as long as the sub-limits are not exceeded

  • Pro-rated 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

  • 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

Download shows Benefits across all Options

Value Option: 2020 Benefits

IN-HOSPITAL BENEFITS

In-House Benefits Subject to Authorisation


Private Hospitals

  • 100% of Scheme Tariff*
  • Unlimited benefits subject to pre-authorisation, clinical protocols and formulary*
  • Subject to sub-limits not being exceeded
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 2 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, and psychiatry/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, 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




In-House Benefits with No Annual Limit


Internal and External Prosthesis

  • 100% of Negotiated Tariff*
  • Subject to PMB’s, pre-authorisation and protocols
  • Limited to R47 990 per family per annum
Sub-Limits: Back /Spinal instrumentation and disc prosthesis
  • Limited to a maximum of 2 levels unless clinically motivated and approved or within PMB protocols
  • R23 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
    • Internal sphincters and stimulators
    • Neurostimulators/internal nerve stimulator for Parkinson‘s Disease No benefit
    • Cochlear implants Subject to overall limit for prosthesis benefit
    • 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 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*
  • Subject to PMB’s, pre-authorisation and protocols
  • Limited to 14 days per beneficiary per annum
Circumcision
  • In and out of hospital
  • 100% of Scheme Tariff*
  • Subject to pre-authorisation
  • In and Out of hospital
Hyperbaric Oxygen Therapy
  • 100% of Negotiated Tariff*
  • Subject to PMB’s, pre-authorisation and protocols
  • Limited to R42 536 per family per annum
Negative Pressure Wound Therapy
  • 100% of Negotiated Tariff*
  • Subject to PMB’s, pre-authorisation and protocols
  • Limited to R26 803 per family per annum
Medication for Age Related Macular Degeneration
  • Subject to PMB’s, pre-authorisation and Scheme formulary* and protocol
  • 100% of Negotiated Tariff*
Back Surgery
  • Subject to PMB’s, pre-authorisation and protocols
  • 100% of Scheme Tariff*
  • 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
  • (In conjunction with the Overall Scheme Exclusion List and subject to PMB’s)
  • Refer to Scheme Exclusion list
Deductible* Applied for In-Hospital Procedures
  • Deductible* of R 5 000 will apply to the below procedures inhospital 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





MATERNITY BENEFITS

Maternity Visits


Additional 6 GP consultations and 3 specialist consultations per Pregnancy at GP or Specialist (in addition to normal consultation limit)




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*




Home 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




Qualifying Provisions


  1. Members qualify for wellness benefits (only 1 per member per annum paid from risk)
  2. Wellness testing provided at an Employee Wellness Event will be claimed from this benefi
  3. Members qualify for the above additional benefits at 100% of Scheme Tariff*/Cost: (1 per beneficiary per annum)
  4. Wellness testing provided at an Employee Wellness Event will be claimed from this benefit.





WELLNESS BENEFITS

Mammogram


Female beneficiaries over 40 years




Pap smear


Female beneficiaries over 18 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 years




Blood Pressure Check


  • All beneficiaries Reimbursement of Blood
  • Pressure Monitors on all Options




Flu Vaccination


All beneficiaries




Pneumococcal Vaccination


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





OUT-OF-HOSPITAL BENEFITS

DAY-TO-DAY BENEFITS






MONTHLY CONTRIBUTIONS

Principal Member


Sole Member: R3,493 Total Monthly Contribution: R 3,493




Member PLUS Adult


Principal Member: R 3,493 Adult Beneficiary: R 2,554 Total Monthly Contribution: R 6,047




Member PLUS 1 Child


Principal Member: R 3,493 Child Beneficiary: R 594 Total Monthly Contribution: R 4,087




Member PLUS Adult PLUS 1 Child


Principal Member: R3,493 Adult Beneficiary: R 2,554 Child Beneficiary: R 594 Total Monthly Contribution: R 6,641




Member PLUS Adult PLUS 2 Children


Principal Member: R 3,493 Adult Beneficiary: R 2,554 Child Benefiary 1: R 594 Child Beneficiary 2: R 594 Total Monthly Contribution: R 7,235




Family (Member PLUS Adult PLUS 3 Children)


Principal Member: R 3,493 Adult Beneficiary: R 2,554 Child Beneficiary 1: R 594 Child Beneficiary 2: R 594 Child Beneficiary 3: R 594 Total Monthly Contribution: R 7,829





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2020 by Hosmed Medical Scheme. Proudly created by Veritech ICT Solutions (Pty) Ltd

3 Victoria Link, Route 21 Corporate Park, Irene, 0178

0861 hosmed (467 633)

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