Hosmed Access medical aid plan: 2017

Out-of-hospital, scheme pays for some: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, supplementary services, maternity benefits, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB. Pay for maximum 3 children.

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IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
Overall Annual Limit (OAL):
R1,250,000
Contributions:
Main: Adult: Child:
Total Cost: R2,124 R1,829 R413
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, supplementary services, maternity benefits, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Hospital Choice:
  • Netcare
Specialised Radiology:
  • 2 scans per person, in and out of hospital
Supplementary Services: (Physio, etc)
Transplants:
  • paid by scheme
Co-payments: Some co-payments apply
Alternatives to hospitals:
  • No benefit

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Network GP: Unlimited
  • Non-network: 3 consults per person and 5 consults per family
Overall Annual Limit (OAL):
R1,250,000
Contributions:
Main: Adult: Child:
Total Cost: R2,124 R1,829 R413
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, supplementary services, maternity benefits, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Specialists consultations:
  • Network: 3 consults per person and 5 consults per family
Pathology:
  • R1,800 per person
  • Shared with radiology benefit
General radiology:
  • R1,800 per person
  • Shared with pathology benefit
Specialised radiology:
  • 2 scans per person
Supplementary Services: (Physio, etc)
  • R1,590 per person and R5,300 per family

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MATERNITY BENEFITS:
Hospital stay:
  • Natural Birth: 2 days
  • Caesar: 3 days
  • Home Births: R4,000 per pregnancy
Overall Annual Limit (OAL):
R1,250,000
Contributions:
Main: Adult: Child:
Total Cost: R2,124 R1,829 R413
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, supplementary services, maternity benefits, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Consultations:
  • Additional 3 visits per pregnancy at GP and 2 visits at Specialist
Scans:
  • 2 x 2D scans

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • PMB level of care

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):
R1,250,000
Contributions:
Main: Adult: Child:
Total Cost: R2,124 R1,829 R413
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, supplementary services, maternity benefits, preventative benefits. 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: paid by scheme
  • Specialised dentistry: 1 set acrylic/plastic dentures per person every 4 years
Overall Annual Limit (OAL):
R1,250,000
Contributions:
Main: Adult: Child:
Total Cost: R2,124 R1,829 R413
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, supplementary services, maternity benefits, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Orthodontics:
  • No benefit
Maxillo Facial Surgery:

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MEDICATION:
Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
R1,250,000
Contributions:
Main: Adult: Child:
Total Cost: R2,124 R1,829 R413
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, supplementary services, maternity benefits, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Acute (presrcibed) medication:
  • Unlimited if dispensed by network GP
  • R1,700 per person, and R4,200 per family if obtained from pharmacy
Over-the-counter:
  • R475 per family, with a maximum of R85 per script
Birth Control:
  • R70 per person, limited to R840 per family per year
On Discharge:
  • 5 days
Notes: Medicines paid at reference price, subject to formulary

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OPTOMETRY:
Optometry:
  • Benefit available every 24 months
  • Frames: R315 per person
  • Lens: R165 each; Bifocal/Multifocal: R360 each
  • Contact lenses: R840 per person
Overall Annual Limit (OAL):
R1,250,000
Contributions:
Main: Adult: Child:
Total Cost: R2,124 R1,829 R413
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, supplementary services, maternity benefits, preventative benefits. 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):
R1,250,000
Contributions:
Main: Adult: Child:
Total Cost: R2,124 R1,829 R413
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, supplementary services, maternity benefits, preventative benefits. 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:
  • R5,600 per family, PMBs only
Overall Annual Limit (OAL):
R1,250,000
Contributions:
Main: Adult: Child:
Total Cost: R2,124 R1,829 R413
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, supplementary services, maternity benefits, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

1.1. Hearing Aids:
  • See "General Appliances" limit
1.2. Wheelchairs:
  • See "General Appliances" limit
Dialysis: -
HIV:
  • 100% scheme rate
  • Since HIV is a PMB certain out-of-hospital benefits are automatically covered by all schemes according to protocols
Emergency Transport: Netcare911
International Coverage: -
Other: -

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WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
  • Covered
Overall Annual Limit (OAL):
R1,250,000
Contributions:
Main: Adult: Child:
Total Cost: R2,124 R1,829 R413
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, supplementary services, maternity benefits, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Pneumonia vaccines:
Back Rehabilitation Programme:
Biometric Screening:
  • Covered
Child Immunisation:
  • Covered
Pap Smear:
  • Covered, 18yrs+
Mammogram:
  • Covered, 40yrs+ every two years
PAS Test:
  • Covered, 40yrs+
HIV Test:
  • Covered

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PROSTHESIS:
Overal Limit:
Overall Annual Limit (OAL):
R1,250,000
Contributions:
Main: Adult: Child:
Total Cost: R2,124 R1,829 R413
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, supplementary services, maternity benefits, preventative benefits. 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