Bonitas BonEssential medical aid plan: 2019

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Please note that these benefits are still being updated as more information is made available to us. Always consult with your broker before making final decisions regarding your healthcare cover.

Essential
2018 Costs:
Total Cost pm:

Main member:

R1,604

Adult:

R1,227

Child: (Pay only for first 3)

R470
Savings Account:
  • No savings option on this plan
2019 Costs:
Total Cost pm:

Main member:

R1,731
(7.92%)

Adult:

R1,324

Child: (Pay only for first 3)

R507
Savings (per year):
  • No savings option on this plan
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In brief (2018):
  • Scheme rate is 100%, and most day-to-day expenses are paid from out of pocket
  • There are co-payment for 22 procedures
  • Bonitas does pay for most maternity expenses, preventative benefits such as mammograms and pap smears, contraceptives, terminal care, in and out of hospital MRIs, and mental health benefits
  • Cover for 27 chronic conditions
  • Generous benefits for travel insurance
  • Diagnosis and treatment of the 270 PMBs is always paid by scheme, in and out of hospital, according to protocols.
See full benefits below

IN HOSPITAL PROCEDURES:
Essential
Scheme Benefits: Gap Benefits:
Specialists:
  • Up to 100% scheme rate
  • Contracted Specialists: covered in full
  • You or gap cover pay the balance, if any
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
  • Recommended for this plan: Plan Blue, R295pm per family where no member is older than 64yrs (otherwise, R435pm per family)
Hospital Choice:
  • Choose any hospital , but a 30% co-payment may apply for admission to certain hospitals
  • No extra benefit
Specialised Radiology:
  • R 15,000 per family
  • Sublimit increased as necessary, subject to procedure being approved by medical aid
Supplementary Services: (Physio, etc)
  • Up to 100% scheme rate
  • Physical rehabilitation: R49,610 per family
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
  • No extra benefit for rehabilitation
Transplants:
  • 100% scheme rate
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
Co-payments:
  • Colonoscopy,
  • Conservative back treatment
  • Cystoscopy,
  • Facet joint injections,
  • Flexible sigmoidoscopy,
  • Functional nasal surgery,
  • Gastroscopy,
  • Hysteroscopy,
  • Myringotomy,
  • Tonsillectomy and adenoidectomy
  • Umbilical hernia repair
  • Varicose vein surgery:
  • R1,450 co-payment paid by you or your gap cover
  • Arthroscopy,
  • Diagnostic laparoscopy,
  • Laparoscopic hysterectomy (except cancer and PMBs),
  • Laparoscopic appendectomy,
  • Percutaneous rhizotomies,
  • R3,680 co-payment paid by you or your gap cover
  • Back surgery including spinal fusion,
  • Joint replacements,
  • Laparoscopic pyeloplasty,
  • Laparoscopic radical prostatectomy,
  • Nissen fundoplication (reflux surgery),
  • R7,250 co-payment paid by you or your gap cover
  • Gap cover pays co-payments for procedures approved by medical aid
Alternatives to hospitals:
  • Alternatives to hospitalisation: R16,550 per family paid by Bonitas
  • Terminal care: Unlimited, including hospice/private nursing, home oxygen, pain management, psychologists, social workers.
  • No extra benefit available
Casualty:
  • Accident and trauma related costs covered if authorised within 24hrs
  • Pays up to R20,000 per person per year for emergency medical treatment not paid for by medical aid
Other:
  • N/A
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R150,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R150,000 limit)
  • Gap only supplements payment for procedures approved or authorised by your medical aid, and does not cover “penalties” (such as if, for example, you choose a non-DSP doctor for your procedure when the plan required a DSP doctor)
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All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme.
The gap benefits listed are for AskAdam gaps, unless otherwise stated. Actual benefits depend on gap choice option.

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OUT OF HOSPITAL BENEFITS (non-PMB):
Essential
Scheme Benefits Gap benefits
Main: Adult: Child:
Savings /yr: No savings option on this plan
General info:
  • This plan has no savings fund, so most out of hospital costs are paid by you
  • Remember, out of hospital costs authorised as part of PMB treatment (eg. cancer, asthma or stroke) are always paid by the scheme, even on this plan.
  • Our recommended gap cover does not pay out-of-hospital claims, unless it is for cancer treatment, dialysis, or MRI/CT scans
GP consultations:
  • No benefit, unless PMB
  • No extra benefit available
Childcare:
  • Hearing screening for newborns, in or out of hospital
  • Congenital hypothyroidism screening for infants under 1 month old
  • GP consult: one per child 2-12yrs
  • No extra benefit available
Specialists consultations:
  • No benefit, unless PMB
  • No extra benefit available
Pathology:
  • No benefit, unless PMB
  • No extra benefit available
General radiology:
  • No benefit, unless PMB
  • No extra benefit available
Specialised radiology:
  • No benefit, unless PMB
  • No extra benefit available
Supplementary Services: (Physio, etc)
  • No benefit, unless PMB
  • No extra benefit available
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MATERNITY BENEFITS:
Essential
Scheme Benefits Gap benefits
Hospital stay:
  • 100% scheme rate
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
Consultations:
    Paid by Bonitas:
  • 6 consults with GP/gynae/midwife
  • 4 consults with midwife after delivery
  • No extra benefit available
Scans:
    Bonitas pays for:
  • 2 x 2D scans
  • 1 amniocentesis
  • No benefit, unless PMB
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CANCER (ONCOLOGY):
Essential
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • R344,500 per family at preferred provider
  • Brachytherapy: R44,220
  • Once you or the medical scheme have spent R200,000 per oncology treatment cycle from a private hospital, the gap cancer benefit will cover costs authorised but not paid by your medical scheme (up to the R150,000 per person per year gap limit) More info
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DENTISTRY:
Essential
Scheme Benefits Gap benefits
Standard Dentistry:
  • No benefit
Specialised Dentistry:
  • No benefit
  • Pays shortfalls and co-payments for any non-PMB in-hospital dentistry treatment approved by scheme. (PMB are paid in full by scheme if you use DSP)
In-Hospital Dentistry:
  • Dental and oral surgery: no benefit, unless PMB
Orthodontics:
  • No benefit
Maxillo Facial Surgery:
  • No benefit, unless PMB
  • Pays shortfalls and co-payments for any non-PMB in-hospital dentistry treatment approved by scheme. (PMB are paid in full by scheme if you use DSP)
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MEDICATION:
Essential
Scheme Benefits Gap benefits
Chronic:
  • Conditions covered:27 CDL conditions
  • Co-payment for use of non-formulary: 40%
  • No extra benefit available
Acute (presrcibed) medication:
  • No benefit
  • No extra benefit available
Over-the-counter:
  • No benefit
  • No extra benefit available
Birth Control:
  • R1,260 per family, paid by Bonitas
  • No extra benefit available
On Discharge:
  • R380 per person per admission
  • No extra benefit available
Biological:
  • No benefit, unless PMB level of care
  • No extra benefit available
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OPTOMETRY:
Essential
Scheme Benefits Gap benefits
Optometry:
Limit:No benefit
Consult:n/a
Frames:n/a
Single lensesn/a
Bifocals:n/a
Multifocalsn/a
Contactsn/a
Refractive Surgery:n/a
Notes:n/a
  • Pays shortfalls and co-payments for in-hospital or day-clinic treatment approved by scheme
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MENTAL HEALTH:
Essential
Scheme Benefits Gap benefits
In-hospital:
  • In-hospital: R32,210 per family. PMBs always paid in full at DSP, and include up to 21 days admission
  • No extra benefit available
Out-of-hospital:
  • Out-of-hospital: PMBs always paid in full at DSP
  • No extra benefit available
Trauma:
  • PMB conditions are covered for in and out of hospital treatment. For a full list see here.
  • Example of PMB condition: Acute stress disorder accompanied by recent significant trauma, including physical or sexual abuse. Treatment includes hospital admission for psychotherapy / counselling up to 3 days, or up to 12 outpatient psychotherapy / counselling contacts
  • No extra benefit available
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OTHER BENEFITS:
Essential
Scheme Benefits Gap benefits
General Appliances:
  • You pay this out of pocket
  • No benefit
1.1. Hearing Aids:
  • You pay this out of pocket
  • No benefit
1.2. Wheelchairs:
  • You pay this out of pocket
  • No benefit
Dialysis:
  • Unlimited (in-hospital) at DSP. 20% co-payment if DSP is not used.
  • No extra benefit available
HIV:
  • In-hospital: Unlimited if you register on the HIV/AIDS programme
  • Since HIV is a PMB certain out-of-hospital benefits are automatically covered by all schemes according to protocols
  • No benefit
Emergency Transport: ER24
  • No benefit
International Insurance:
  • R5 million per person, per trip. R10 million per family
  • Includes mandatory vaccines
  • No benefit
Other: .
  • No benefit, unless PMB
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WELLNESS/PREVENTATIVE BENEFITS:
Essential
Scheme Benefits Gap benefits
Flu vaccination:
  • Covered
  • No benefit
Pneumonia vaccines:
  • Covered, 65yrs+ every 5 yrs
  • No benefit
Back Rehabilitation Programme:
  • Managed back and neck program offers personalised treatment plan for up to 6 weeks, paid by scheme
  • No benefit
Biometric Screening:
  • Covered
  • No benefit
Child Immunisation:
  • No benefit
  • No benefit
Pap Smear:
  • Covered, every 3 years for women 21yrs-65yrs.
  • No benefit
Mammogram:
  • 1 mammogram every two years, for women 40yrs+
  • No benefit
PAS Test:
  • 1 test for men 45-69yrs, who are high risk for prostate cancer
  • No benefit
HIV Test:
  • Covered
  • No benefit
Other:
  • One stool test for colon cancer, 50yrs-75yrs
  • Wellness Extender: costs R910 per family and includes choice from following: GP consult(s), Biokineticist, Dietician, Physiotherapy consult and a smoking cessation program
  • No benefit
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PROSTHETICS:
Essential
Scheme Benefits Gap benefits
Overal Limit:
  • Internal: R31,500 per family, excluding joint replacement prosthesis
  • External: PMBs only
  • No benefit, unless PMB
Sub-limits:
  • No benefit, unless PMB
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    Important!
  • Unless specified, assume that all benefits are paid are paid at 100% scheme rate
  • No limits or co-payments can apply to treatment of PMBs, which is always unlimited, although subject to strict protocols and scheme rules.
  • “Unlimited” benefits are still subject to authorisation, protocols and sublimits
  • Assume that all benefits need to be pre-authorised