Commed Roots B medical aid plan: 2017

Out-of-hospital, scheme pays for some:GPs, specialits, dentistry, medicine, optometry, radiology, pathology, external applianes, alternative to hopitalisation. Limits apply. All else paid from out of pocket, unless PMB. Pay for all children. Income-limited plan: R6,001-R18,000pm only

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IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
Overall Annual Limit (OAL):
R400k per person, R800k per family
Contributions:
Main: Adult: Child:
Total Cost: R950 R950 R458
Children: Pay for all children
Income limit: R6,001-R18,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:GPs, specialits, dentistry, medicine, optometry, radiology, pathology, external applianes, alternative to hopitalisation. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Hospital Choice:
  • Network
Specialised Radiology:
Supplementary Services: (Physio, etc)
Transplants:
Co-payments:
  • Arthroscopy: R3,000 co-payment
  • Circumcision (elective): R2,000 co-payment
  • Colonoscopy, sigmoidoscopy, proctoscopy: R2,500 co-payment
  • Cystoscopy: R2,000 co-payment
  • Dental admissions: R2,000 co-payment
  • Excision nail bed: R2,000 co-payment
  • Gastroscopy: R2,500 co-payment
  • Hernia repair: R2,500 co-payment
  • Hysterectomy: R3,500 co-payment
  • Hysteroscopy: R3,500 co-payment
  • Joint Replacements: R6,000 co-payment
  • Laparoscopic procedures: R3,500 co-payment
  • Myringotomy: R2,000 co-payment
  • Nasal Surgery: R2,500 co-payment
  • Reflux surgery: R3,500 co-payment
  • Skin lesions: R2,000 co-payment
  • Spinal surgery: R6,000 co-payment
  • Urinary incontinence repair: R4,000 co-payment
  • Varicose veins: R4,000 co-payment
Alternatives to hospitals:
  • Physical rehabilitation, sub-acute facilities, nursing services, hospice: 14 days per person

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Network GP: Unlimited
  • Non-network GP: 3 consults per family limited to R1,000 per family
Overall Annual Limit (OAL):
R400k per person, R800k per family
Contributions:
Main: Adult: Child:
Total Cost: R950 R950 R458
Children: Pay for all children
Income limit: R6,001-R18,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:GPs, specialits, dentistry, medicine, optometry, radiology, pathology, external applianes, alternative to hopitalisation. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Specialists consultations:
  • R2,500 per person and R5,000 per family
Pathology:
  • Paid from day-to-day benefit
General radiology:
  • Paid from day-to-day benefit
Specialised radiology:
  • Paid from day-to-day benefit
Supplementary Services: (Physio, etc)
  • Paid from day-to-day benefit

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MATERNITY BENEFITS:
Hospital stay:
Overall Annual Limit (OAL):
R400k per person, R800k per family
Contributions:
Main: Adult: Child:
Total Cost: R950 R950 R458
Children: Pay for all children
Income limit: R6,001-R18,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:GPs, specialits, dentistry, medicine, optometry, radiology, pathology, external applianes, alternative to hopitalisation. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Consultations:
  • Paid from GP or Specialist benefit
Scans:
  • 1 x 2D scans

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • R165,000 per person at DSP

Note: All oncology benefits are assessed on a case-by-case basis, and are subject to protocols, preferred providers and scheme rules. Benefit covers out-of-hospital treatment too, like chemotherapy.
Overall Annual Limit (OAL):
R400k per person, R800k per family
Contributions:
Main: Adult: Child:
Total Cost: R950 R950 R458
Children: Pay for all children
Income limit: R6,001-R18,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:GPs, specialits, dentistry, medicine, optometry, radiology, pathology, external applianes, alternative to hopitalisation. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

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DENTISTRY:
Dentistry:
  • Standard dentistry: consultations, extractions, fillings, scaling and polishing, 1 set of plastic dentures every 2 years. Paid by scheme.
  • Specialised dentistry: no benefit
Overall Annual Limit (OAL):
R400k per person, R800k per family
Contributions:
Main: Adult: Child:
Total Cost: R950 R950 R458
Children: Pay for all children
Income limit: R6,001-R18,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:GPs, specialits, dentistry, medicine, optometry, radiology, pathology, external applianes, alternative to hopitalisation. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Orthodontics:
Maxillo Facial Surgery:

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MEDICATION:
Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
  • Paid at formulary reference price
Overall Annual Limit (OAL):
R400k per person, R800k per family
Contributions:
Main: Adult: Child:
Total Cost: R950 R950 R458
Children: Pay for all children
Income limit: R6,001-R18,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:GPs, specialits, dentistry, medicine, optometry, radiology, pathology, external applianes, alternative to hopitalisation. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Acute (presrcibed) medication:
  • Paid from day-to-day benefit
Over-the-counter:
  • Paid from day-to-day benefit
Birth Control:
On Discharge:
Notes:
  • PMBs: Single exit price t plus dispensing fee
  • Otherwise, subject to formulary reference price

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OPTOMETRY:
Optometry:
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
R400k per person, R800k per family
Contributions:
Main: Adult: Child:
Total Cost: R950 R950 R458
Children: Pay for all children
Income limit: R6,001-R18,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:GPs, specialits, dentistry, medicine, optometry, radiology, pathology, external applianes, alternative to hopitalisation. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
Overall Annual Limit (OAL):
R400k per person, R800k per family
Contributions:
Main: Adult: Child:
Total Cost: R950 R950 R458
Children: Pay for all children
Income limit: R6,001-R18,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:GPs, specialits, dentistry, medicine, optometry, radiology, pathology, external applianes, alternative to hopitalisation. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:


Out-of-hospital:

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OTHER BENEFITS:
General Appliances:
  • R8,000 per family
  • Stoma care: from day-to-day benefit
Overall Annual Limit (OAL):
R400k per person, R800k per family
Contributions:
Main: Adult: Child:
Total Cost: R950 R950 R458
Children: Pay for all children
Income limit: R6,001-R18,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:GPs, specialits, dentistry, medicine, optometry, radiology, pathology, external applianes, alternative to hopitalisation. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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1.1. Hearing Aids:
  • Paid from day-to-day benefit every 2 years
1.2. Wheelchairs:
  • Every 3 years, subject to above limit
Dialysis:
HIV:
Emergency Transport: ER24
International Coverage:
  • Emergency cover in SADC countries
Other:

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WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
Overall Annual Limit (OAL):
R400k per person, R800k per family
Contributions:
Main: Adult: Child:
Total Cost: R950 R950 R458
Children: Pay for all children
Income limit: R6,001-R18,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:GPs, specialits, dentistry, medicine, optometry, radiology, pathology, external applianes, alternative to hopitalisation. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Pneumonia vaccines:
Back Rehabilitation Programme:
Biometric Screening:
Child Immunisation:
Pap Smear:
Mammogram:
  • Covered for 49yrs+, every 2 years.
  • Limited to R2,500 and with R500 co-payment
PAS Test:
HIV Test:

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PROSTHESIS:
Overal Limit:
Overall Annual Limit (OAL):
R400k per person, R800k per family
Contributions:
Main: Adult: Child:
Total Cost: R950 R950 R458
Children: Pay for all children
Income limit: R6,001-R18,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:GPs, specialits, dentistry, medicine, optometry, radiology, pathology, external applianes, alternative to hopitalisation. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Sub-limits:

    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