Sizwe Affordable Care B medical aid plan: 2018

View all plans in this scheme.
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.

Affordable Care B
2018 Costs:
Total Cost pm:

Main member:

R2,928

Adult:

R2,688

Child: (Pay for all)

R680
Savings Account:
  • No savings option on this plan
Extended Fund: R R R
2019 Costs:
Total Cost pm:

Main member:

R
(%)

Adult:

R

Child: (Pay for all)

R
Income band:
In brief (2018): See full benefits below

IN HOSPITAL PROCEDURES:
Affordable Care B
Scheme Benefits: Gap Benefits:
Specialists:
  • 100% scheme rate
  • 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
  • No benefit
Specialised Radiology:
  • Limited to R28,400 per family
  • In and out of hospital
  • Sublimit increased as necessary
  • Out of hospital, co-payment and sublimit increase is for MRI and CT scans only
Supplementary Services: (Physio, etc)
  • 100% scheme rate
  • Dietician, speech therapy, occupational therapy: subject to PMBs
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals, for non-PMB treatment approved by medical aid
  • No benefit for out-of-hospital services
Transplants:
  • PMBs only
  • No extra benefit available (PMB benefits are paid in full by medical aid)
Co-payments: .
Alternatives to hospitals:
  • Private nursing: R6,780 per family
Casualty: 2018 benefits are coming soon!
  • Pays up to R20,000 per person per year for emergency medical treatment not paid for by medical aid
Other:
  • Blood transfusion: PMBs only
  • No benefit
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)

No phone calls!
Our quote will include the right gap cover for this plan

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.

.
.
.
.
OUT OF HOSPITAL BENEFITS (non-PMB):
Affordable Care B
Scheme Benefits Gap benefits
Main: Adult: Child:
Savings /yr: No savings option on this plan
Extended Fund: R R R
General info:
  • Our recommended gap cover does not pay out-of-hospital claims, unless it is for cancer treatment, dialysis, or MRI/CT scans
GP consultations:
  • M =7 consults; M1 =14 consults; M2 =16 consults; M3 =18 consults etc
Childcare:
  • No extra benefit available
Specialists consultations:
  • Must be referred. Limited consults to: M =4 consults; M1 =8; M2 =9; M3 =10; M4 =11; M5 =12; M6+ =13
Pathology:
  • Paid from day-to-day benefit
General radiology:
  • Paid from day-to-day benefit
Specialised radiology:
  • R28,400 per family, in and out of hospital
Supplementary Services: (Physio, etc)
  • Physio: from day-to-day benefit
  • Otherwise, R1,510 per person and R2,640 per family, paid by scheme

No phone calls!
Our quote will include the right gap cover for this plan

.
.
MATERNITY BENEFITS:
Affordable Care B
Scheme Benefits Gap benefits
Hospital stay:
  • 100% scheme rate
Consultations:
  • 9 consults with GP or midwife
  • 4 consults with OB, on referral
  • Paid by scheme
Scans:
  • 2 x 2D scans

No phone calls!
Our quote will include the right gap cover for this plan

.
.
CANCER (ONCOLOGY):
Affordable Care B
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • R314,170 per family

No phone calls!
Our quote will include the right gap cover for this plan

.
.
DENTISTRY:
Affordable Care B
Scheme Benefits Gap benefits
Dentistry:
  • Standard: two consults per person, fillings and root canals if motivated
  • Plastic dentures: 1 set per jaw per person, every 4 years
  • Specialised: 1 crown per family
  • Dentures: Partial frames per person every 5 years, limited to 1 person per year
  • In-hospital: subject to authorisation, with R1,500 co-payment
Orthodontics:
  • Under 18yrs, with 35% co-payment
  • No extra benefit available
Maxillo Facial Surgery: 2018 benefits are coming soon!
  • 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)

No phone calls!
Our quote will include the right gap cover for this plan

.
.
MEDICATION:
Affordable Care B
Scheme Benefits Gap benefits
Chronic:
  • non-PMB: M=R5,540
    M+1= R11,090
    M+2=R16,640
    M+3=R22,190
    M+4=R27,730
    M+5=R33,300
    M+6=R38,850
Acute (presrcibed) medication:
  • Paid from day-to-day benefit, with following sub limits:
M =R3,420
M1 =R5,210
M2 =R6,160
M3 =R6,630
M4 =R7,580
M5 =R7,820
M6+ =R8,060
Over-the-counter:
Birth Control:
  • R2,620 per family
On Discharge:
Biological:
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

.
.
OPTOMETRY:
Affordable Care B
Scheme Benefits Gap benefits
Optometry:
  • Frames: R800 per person every 2 years
  • Lenses: R175 per lend for single, R380 for bifocal, R695 for multifocal, every 2 years
  • Contact lenses: R1,500 per person
  • Refractive surgery: R6,310 per per family
  • Pays shortfalls and co-payments for any non-PMB in-hospital treatment approved by scheme. (PMBs are paid in full by scheme if you use DSP)

No phone calls!
Our quote will include the right gap cover for this plan

.
.
MENTAL HEALTH:
Affordable Care B
Scheme Benefits Gap benefits
In-hospital:
  • 21 days per person
  • Addiction: PMBs only, 3 days withdrawal treatment and 21 days rehab
Out-of-hospital:
  • R8,580 per family, paid by scheme
Trauma:

No phone calls!
Our quote will include the right gap cover for this plan

.
.
OTHER BENEFITS:
Affordable Care B
Scheme Benefits Gap benefits
General Appliances:
  • M =R1,510 and M1+ = R2,640. in or out of hospital
  • No benefit
1.1. Hearing Aids:
  • R12,000 per family, once every 3 years
  • No benefit
1.2. Wheelchairs:
  • R3,150 per family, once every 4 years
  • No benefit
Dialysis:
  • PMBs only
HIV:
  • Subject to treatment protocols
  • No benefit
Emergency Transport: Europ Assist
  • No benefit
International Insurance: 2018 benefits are coming soon!
  • No benefit
Other: 2018 benefits are coming soon!

No phone calls!
Our quote will include the right gap cover for this plan

.
.
WELLNESS/PREVENTATIVE BENEFITS:
Affordable Care B
Scheme Benefits Gap benefits
Flu vaccination: TBC
  • No benefit
Pneumonia vaccines: TBC
  • No benefit
Back Rehabilitation Programme: 2018 benefits are coming soon!
  • No benefit
Biometric Screening: 2018 benefits are coming soon!
  • No benefit
Child Immunisation: 2018 benefits are coming soon!
  • No benefit
Pap Smear: TBC
  • No benefit
Mammogram: TBC
  • No benefit
PAS Test: TBC
  • No benefit
HIV Test: 2018 benefits are coming soon!
  • No benefit
Other:
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

.
.
PROSTHETICS:
Affordable Care B
Scheme Benefits Gap benefits
Overal Limit:
  • R42,670 per person
Sub-limits:
  • Cardiac stents: 3 per family
  • Vascular stents: 2 per family

No phone calls!
Our quote will include the right gap cover for this plan


    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