Cape Medical Silver medical aid plan: 2017

Pay for all 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: R1,704 R1,704 R258
Children: Pay for all children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R3,000 R3,000 R456

Compare with these plans:
Hospital Choice:
  • Unlimited for non PMBs
  • PMBs: State or simialar facility, nominated by scheme
Specialised Radiology:
  • R10,220 per person with a R1,500 co-payment in and out of hospital
  • Thereafter, from day-to-day benefit
Supplementary Services: (Physio, etc)
Transplants:
  • PMB level of care
Co-payments:
  • Arthroscopy, appendectomy, inguinal hernia repair, gynaecological procedures, urology procedures, umbilical hernia repair, incisional hernia repair, ventral hernia repair, colectomy, colonoscopy, gastroscopy, hysteroscopy, sympathectomy, vaginal hysterectomy, cystoscopy: R1,000 co-payment
Alternatives to hospitals:
  • Hospice and registered nurses: up to 15 days per person

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • GP consults: 2 per person paid by scheme. Thereafter, from day-to-day benefit
  • Paediatric consults: R 780 per child. Thereafter, from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,704 R1,704 R258
Children: Pay for all children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R3,000 R3,000 R456

Compare with these plans:

Specialists consultations:
  • Paid from day-to-day benefit
Pathology:
  • Covered if Lancet or Pathcare is used
General radiology:
  • Paid from day-to-day benefit
Specialised radiology:
  • R10,220 per person with a R1,500 co-payment in and out of hospital
  • Thereafter, 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):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,704 R1,704 R258
Children: Pay for all children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R3,000 R3,000 R456

Compare with these plans:

Consultations:
  • Consults: R1,995 per family, including scans. Paid by scheme.
  • Thereafter, from day-to-day benefit
Scans:
  • R1,995 per family, including consults
  • Thereafter, from day-to-day benefit

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • PMBs only, at state or similar facilities
  • Subject to SAOC Tier 1 treatment guidelines

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: R1,704 R1,704 R258
Children: Pay for all children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R3,000 R3,000 R456

Compare with these plans:

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DENTISTRY:
Dentistry:
  • Standard dentistry: R450 per person, paid by scheme. Thereafter, from day-to-day benefit
  • Specialised dentistry: from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,704 R1,704 R258
Children: Pay for all children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R3,000 R3,000 R456

Compare with these plans:

Orthodontics:
  • Paid from day-to-day benefit
Maxillo Facial Surgery:

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MEDICATION:
Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,704 R1,704 R258
Children: Pay for all children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R3,000 R3,000 R456

Compare with these plans:
Acute (presrcibed) medication:
  • R440 per family. Thereafter from day-to-day benefit
Over-the-counter:
  • Paid from day-to-day benefit
Birth Control:
  • Paid from day-to-day benefit
On Discharge:
  • Paid from acute medicine benefit
Notes:
  • Medicines are paid at cost to a maximum of Single Exit price plus dispensing fee

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OPTOMETRY:
Optometry:
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,704 R1,704 R258
Children: Pay for all children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R3,000 R3,000 R456

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
  • Paid from day-to-day benefit, unless PMB
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,704 R1,704 R258
Children: Pay for all children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R3,000 R3,000 R456

Compare with these plans:


Out-of-hospital:
  • Paid from day-to-day benefit, unless PMB

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OTHER BENEFITS:
General Appliances:
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,704 R1,704 R258
Children: Pay for all children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R3,000 R3,000 R456

Compare with these plans:

1.1. Hearing Aids:
  • See "General Appliances" limit
1.2. Wheelchairs:
  • See "General Appliances" limit
Dialysis:
  • PMB level of care criteria
HIV:
Emergency Transport:
International Coverage:
Other:

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WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,704 R1,704 R258
Children: Pay for all children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R3,000 R3,000 R456

Compare with these plans:

Pneumonia vaccines:
Back Rehabilitation Programme:
Biometric Screening:
Child Immunisation:
Pap Smear:
Mammogram:
  • R1,320 with R300 co-payment, for women 49yrs+, once every two years
PAS Test:
HIV Test:

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PROSTHESIS:
Overal Limit:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,704 R1,704 R258
Children: Pay for all children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R3,000 R3,000 R456

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