CompCare Networx ED D medical aid plan: 2017

Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB. Pay for all children. Income-limited plan: R8,001-R9,000pm only

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IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
Overall Annual Limit (OAL):
R1,100,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R631 R599 R300
Children: Pay for all children
Income limit: R8,001-R9,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R2,800 (main) R4,170 (family) R

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Hospital Choice:
  • Network (Private)
Specialised Radiology:
Supplementary Services: (Physio, etc)
Transplants:
Co-payments:
Alternatives to hospitals:
  • Step down nursing facilities, hospice and rehabilitation: subject to OAL
  • Private nursing at home: PMBs only

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Selected network GP: Unlimited
  • Non-network GP: 2 consultswith 20% co-payment
Overall Annual Limit (OAL):
R1,100,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R631 R599 R300
Children: Pay for all children
Income limit: R8,001-R9,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R2,800 (main) R4,170 (family) R

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Specialists consultations:
  • 2 consults per person and 3 consults per family
  • Paid from day-to-day benefit
Pathology:
  • Unlimited when clinically appropriate within Universal Network and referred to by network GP
General radiology:
  • Unlimited when clinically appropriate within Universal Network and referred to by network GP
Specialised radiology:
  • No benefit, unless PMB
Supplementary Services: (Physio, etc)
  • No benefit, unless PMB

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MATERNITY BENEFITS:
Hospital stay:
  • Normal birth: 2 days
  • Caesarean: 3 days. No cover for elective.
Overall Annual Limit (OAL):
R1,100,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R631 R599 R300
Children: Pay for all children
Income limit: R8,001-R9,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R2,800 (main) R4,170 (family) R

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Consultations:
  • 2 extra consults with a network Specialist
Scans:

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • Unlimited, subject to protocols
  • Biological medicine: PMB only

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):
R1,100,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R631 R599 R300
Children: Pay for all children
Income limit: R8,001-R9,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R2,800 (main) R4,170 (family) R

Compare with these plans:

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DENTISTRY:
Dentistry:
  • Standard dentistry: one consult per person
  • Specialised dentistry: PMBs only
Overall Annual Limit (OAL):
R1,100,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R631 R599 R300
Children: Pay for all children
Income limit: R8,001-R9,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R2,800 (main) R4,170 (family) R

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Orthodontics:
Maxillo Facial Surgery:

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MEDICATION:
Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 1 condition covered
Overall Annual Limit (OAL):
R1,100,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R631 R599 R300
Children: Pay for all children
Income limit: R8,001-R9,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R2,800 (main) R4,170 (family) R

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Acute (presrcibed) medication:
  • Paid by scheme
Over-the-counter:
  • No benefit
Birth Control:
  • R95 per month
On Discharge:
  • 7 days supply and R 280 per discharge
Notes:
  • Meds must be prescribed by a Universal Network provider and dispensed by network pharmacy
  • Only formulary is covered, unless otherwise authorised
  • Reference pricing

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OPTOMETRY:
Optometry:
  • Paid from day-to-day benefit
  • Lenses and frames: R780 per person for single vision and R1,250 for bi-focals, every second year
Overall Annual Limit (OAL):
R1,100,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R631 R599 R300
Children: Pay for all children
Income limit: R8,001-R9,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R2,800 (main) R4,170 (family) R

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
  • Limited to 21 days per family
Overall Annual Limit (OAL):
R1,100,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R631 R599 R300
Children: Pay for all children
Income limit: R8,001-R9,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R2,800 (main) R4,170 (family) R

Compare with these plans:


Out-of-hospital:

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OTHER BENEFITS:
General Appliances:
Overall Annual Limit (OAL):
R1,100,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R631 R599 R300
Children: Pay for all children
Income limit: R8,001-R9,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R2,800 (main) R4,170 (family) R

Compare with these plans:

1.1. Hearing Aids:
1.2. Wheelchairs:
Dialysis:
HIV:
  • Since HIV is a PMB certain out-of-hospital benefits are automatically covered by all schemes according to protocols
Emergency Transport:
International Coverage:
  • International benefit: subject to benefits per individual benefit category. Paid at South African rates
    Other:
    • Oxygen home ventilation:
    • PMBs only
    • Wound care in lieu of hospitalisation: subject to protocols
    • Trauma: unlimited phone consults with psychologists/social workers and 3 face-to-face sessions per person per year

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    WELLNESS/PREVENTATIVE BENEFITS:
    Flu vaccination:
    • Covered
    Overall Annual Limit (OAL):
    R1,100,000 per family
    Contributions:
    Main: Adult: Child:
    Total Cost: R631 R599 R300
    Children: Pay for all children
    Income limit: R8,001-R9,000 (other limits)
    Day-to-Day Benefit:
    Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
    Main: Adult: Child:
    (S) Savings: R0- R0- R0-
    Extended Fund: R2,800 (main) R4,170 (family) R

    Compare with these plans:

    Pneumonia vaccines:
    Back Rehabilitation Programme:
    Biometric Screening:
    • Covered
    Child Immunisation:
    Pap Smear:
    Mammogram:
    PAS Test:
    HIV Test:

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    PROSTHESIS:
    Overal Limit:
    Overall Annual Limit (OAL):
    R1,100,000 per family
    Contributions:
    Main: Adult: Child:
    Total Cost: R631 R599 R300
    Children: Pay for all children
    Income limit: R8,001-R9,000 (other limits)
    Day-to-Day Benefit:
    Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
    Main: Adult: Child:
    (S) Savings: R0- R0- R0-
    Extended Fund: R2,800 (main) R4,170 (family) R

    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