Hosmed Plus medical aid plan: 2017

Out-of-hospital, scheme pays for some: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, mental health, 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):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,184 R3,115 R700
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, mental health, 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:
  • Unlimited
Specialised Radiology:
  • Unlimited
Supplementary Services: (Physio, etc)
Transplants:
  • paid by scheme
Co-payments: n/a
Alternatives to hospitals:
  • No benefit

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • 16 visits per person, and 26 visits per family
  • Applies to GPs, Specialists and Outpatient Facilities
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,184 R3,115 R700
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, mental health, 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:

Overall out-of-hospital annual limit for : Acute medicine, advanced dentistry, alternative services, biokinetics, physio, remedial and other therapies and mental health:
Main M+1 M+2 M+3
R10,960 R23,090 R25,200 R27,750
Specialists consultations:
  • See GP benefit, above
Pathology:
  • R4,360 per person
General radiology:
  • R3,210 per person
Specialised radiology:
  • 2 scans per person
Supplementary Services: (Physio, etc)
  • Alternative services: R3,495 per family
  • Remedial and other therapies: R4,430 per family
  • Physiotherapy and Biokinetics: R2,340 per person limited to R3,750 per family

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MATERNITY BENEFITS:
Hospital stay:
  • Natural Birth: 2 nights and 3 days
  • Caesar: 3 nights and 4 days
  • Home Births: R6,000 per pregnancy
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,184 R3,115 R700
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, mental health, 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 5 visits per pregnancy at GP or Specialist
  • Antenatal classes: R477 per mother
Scans:
  • 3 x 2D scans

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • R534,000 per person

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):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,184 R3,115 R700
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, mental health, 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: R5,840 per person and R7,360 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,184 R3,115 R700
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, mental health, 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:

Overall out-of-hospital annual limit for : Acute medicine, advanced dentistry, alternative services, biokinetics, physio, remedial and other therapies and mental health:
Main M+1 M+2 M+3
R10,960 R23,090 R25,200 R27,750
Orthodontics:
  • No benefit
Maxillo Facial Surgery:

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MEDICATION:
Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: R12,600 per person, and R24,060 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,184 R3,115 R700
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, mental health, 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:
  • R4,800 per person, and R9,400 per family
Over-the-counter:
  • R975 per family, with a maximum of R191 per script
Birth Control:
  • R120 per person, limited to R1,440 per family per year
On Discharge:
  • 7 days
Notes: Medicines paid at reference price, subject to formulary

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OPTOMETRY:
Optometry:
  • Benefit available every 24 months
  • Frames: R870 per person
  • Lens: R165 each; Bifocal: R360 each; Multifocal: R660 each
  • Contact lenses: R2,915 per person
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,184 R3,115 R700
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, mental health, 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:
  • PMBs: 21 days per person
  • non-PMBs:R19,800 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,184 R3,115 R700
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, mental health, 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:


Overall out-of-hospital annual limit for : Acute medicine, advanced dentistry, alternative services, biokinetics, physio, remedial and other therapies and mental health:
Main M+1 M+2 M+3
R10,960 R23,090 R25,200 R27,750
Out-of-hospital:
  • R4,100 per person and R8,200 per family

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OTHER BENEFITS:
General Appliances:
  • R13,344 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,184 R3,115 R700
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, mental health, 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):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,184 R3,115 R700
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, mental health, 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):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,184 R3,115 R700
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, mental health, 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