Commed Shina A medical aid plan: 2017

Out-of-hospital, scheme pays for some: Alternative to hopitalisation, mammogram and external appliances. Limits apply. All else paid from out of savings or from out of pocket, unless PMB. Pay for all children. Income-limited plan: R0-R6,000pm only

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IN HOSPITAL PROCEDURES:

Payout Rate for Specialists:

100% scheme rate

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
R600k per person, R1,200,000 per family
Contributions:
Total Cost:	R1,498	R1,274	R300
Children:	Pay for all children
Income limit:	R0-R6,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Alternative to hopitalisation, mammogram and external appliances. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R1,798	R1,529	R360

Compare with these plans:

Commed Roots A 2017

Hospital Choice:

Network

Specialised Radiology:

R6,000 per person with a R2,000 co-payment

Supplementary Services: (Physio, etc)

100% scheme rate

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:

Paid from day-to-day benefit

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
R600k per person, R1,200,000 per family
Contributions:
Total Cost:	R1,498	R1,274	R300
Children:	Pay for all children
Income limit:	R0-R6,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Alternative to hopitalisation, mammogram and external appliances. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R1,798	R1,529	R360

Compare with these plans:

Commed Roots A 2017

Specialists consultations:

Paid from day-to-day benefit

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:

100% scheme rate
Elective caesarean: no benefit

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
R600k per person, R1,200,000 per family
Contributions:
Total Cost:	R1,498	R1,274	R300
Children:	Pay for all children
Income limit:	R0-R6,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Alternative to hopitalisation, mammogram and external appliances. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R1,798	R1,529	R360

Compare with these plans:

Commed Roots A 2017

Consultations:

Paid from day-to-day benefit

Scans:

2 x 2D scans

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CANCER (ONCOLOGY):

Overall coverage (in and out of hospital):

R175,000 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.

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
R600k per person, R1,200,000 per family
Contributions:
Total Cost:	R1,498	R1,274	R300
Children:	Pay for all children
Income limit:	R0-R6,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Alternative to hopitalisation, mammogram and external appliances. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R1,798	R1,529	R360

Compare with these plans:

Commed Roots A 2017

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DENTISTRY:

Dentistry:

Paid from day-to-day benefit

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
R600k per person, R1,200,000 per family
Contributions:
Total Cost:	R1,498	R1,274	R300
Children:	Pay for all children
Income limit:	R0-R6,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Alternative to hopitalisation, mammogram and external appliances. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R1,798	R1,529	R360

Compare with these plans:

Commed Roots A 2017

Orthodontics:

Maxillo Facial Surgery:

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MEDICATION:

Chronic:

No. of chronic conditions covered: 27 CDLs and PMBs
Paid at formulary reference price

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
R600k per person, R1,200,000 per family
Contributions:
Total Cost:	R1,498	R1,274	R300
Children:	Pay for all children
Income limit:	R0-R6,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Alternative to hopitalisation, mammogram and external appliances. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R1,798	R1,529	R360

Compare with these plans:

Commed Roots A 2017

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

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
R600k per person, R1,200,000 per family
Contributions:
Total Cost:	R1,498	R1,274	R300
Children:	Pay for all children
Income limit:	R0-R6,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Alternative to hopitalisation, mammogram and external appliances. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R1,798	R1,529	R360

Compare with these plans:

Commed Roots A 2017

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MENTAL HEALTH:

In-hospital:

PMBs only

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
R600k per person, R1,200,000 per family
Contributions:
Total Cost:	R1,498	R1,274	R300
Children:	Pay for all children
Income limit:	R0-R6,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Alternative to hopitalisation, mammogram and external appliances. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R1,798	R1,529	R360

Compare with these plans:

Commed Roots A 2017

Out-of-hospital:

PMBs only

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OTHER BENEFITS:

General Appliances:

R8,000 per family
Stoma care: from day-to-day benefit

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
R600k per person, R1,200,000 per family
Contributions:
Total Cost:	R1,498	R1,274	R300
Children:	Pay for all children
Income limit:	R0-R6,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Alternative to hopitalisation, mammogram and external appliances. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R1,798	R1,529	R360

Compare with these plans:

Commed Roots A 2017

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:

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
R600k per person, R1,200,000 per family
Contributions:
Total Cost:	R1,498	R1,274	R300
Children:	Pay for all children
Income limit:	R0-R6,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Alternative to hopitalisation, mammogram and external appliances. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R1,798	R1,529	R360

Compare with these plans:

Commed Roots A 2017

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:

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
R600k per person, R1,200,000 per family
Contributions:
Total Cost:	R1,498	R1,274	R300
Children:	Pay for all children
Income limit:	R0-R6,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Alternative to hopitalisation, mammogram and external appliances. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R1,798	R1,529	R360

Compare with these plans:

Commed Roots A 2017

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