CompCare Pinnacle medical aid plan: 2017

Comprehensive cover with savings, extended fund, and limited above threshold benefits that cover most out-of-hospital benefits (with limits). Pay for all children.

View all plans in this scheme

IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,328 R4,146 R1,476
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive cover with savings, extended fund, and limited above threshold benefits that cover most out-of-hospital benefits (with limits).
Main: Adult: Child:
(S) Savings: R12,816 R9,936 R3,528
Extended Fund: R3,197 R2,488 R886
(SP) Self Payment: R1,900 R1,416 R460
Threshold (S+SP): R17,913 R13,840 R4,874
Above Threshold: R8,700 pb
R17,400 pf		 17,400 pf

Compare with these plans:
Hospital Choice:
  • Unlimited
Specialised Radiology:
  • First R2,500 payable from available Savings
  • No benefit for screening purposes
Supplementary Services: (Physio, etc)
Transplants:
Co-payments:
  • Excision lesion: R1,000
  • Gastroscopy, colonoscopy, cystoscopy, nasal/sinus endoscopy, functional nasal surgery, hysteroscopy, flexible sigmoidoscopy, arthroscopy, diagnostic laparoscopy, dental, joint replacements, conservative back and neck treatment, laminectomy and spinal fusion and nissen fundoplication (reflux surgery), hysterectomy (except for cancer), laparoscopic hemicolectomy, laparoscopic inguinal hernia repair, laparoscopic appendicectomy: R1,500
  • Specialised radiology: R2,500 co-payment
Alternatives to hospitals:
  • Step down nursing facilities, hospice and rehabilitation: Unlimited
  • Private nursing at home from day-to-day benefit limited to 60 days per family

.
.

OUT OF HOSPITAL BENEFITS:
GP consultations:
    Paid
  • Paid from day-to-day benefit
  • If day-to-day benefit is depleted: 2 additional consults and one ER visit (limited to R1,000) per child younger than 6yrs, paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,328 R4,146 R1,476
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive cover with savings, extended fund, and limited above threshold benefits that cover most out-of-hospital benefits (with limits).
Main: Adult: Child:
(S) Savings: R12,816 R9,936 R3,528
Extended Fund: R3,197 R2,488 R886
(SP) Self Payment: R1,900 R1,416 R460
Threshold (S+SP): R17,913 R13,840 R4,874
Above Threshold: R8,700 pb
R17,400 pf		 17,400 pf

Compare with these plans:

Specialists consultations:
  • Paid from day-to-day benefit, up to 200% scheme rate
  • Above-threshold sub-limit of R4,180 per family applies
Pathology:
  • Paid from day-to-day benefit
  • Above-threshold sub-limit of R4,175 per family
  • Combined with radiology benefit
General radiology:
  • Paid from day-to-day benefit
  • Above-threshold sub-limit of R4,175 per family
  • Combined with pathology benefit
Specialised radiology:
  • First R2,500 paid from available day-to-day benefit, but not from above threshold benefit. Balance paid by scheme.
Supplementary Services: (Physio, etc)
  • R6,950 per family
  • Only physio, biokinetics and OT are payable from above-threshold, and only up to R2,750 per family subject to sub-limits

.
.

MATERNITY BENEFITS:
Hospital stay:
  • Normal birth: 2 days
  • Caesarean: 3 days
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,328 R4,146 R1,476
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive cover with savings, extended fund, and limited above threshold benefits that cover most out-of-hospital benefits (with limits).
Main: Adult: Child:
(S) Savings: R12,816 R9,936 R3,528
Extended Fund: R3,197 R2,488 R886
(SP) Self Payment: R1,900 R1,416 R460
Threshold (S+SP): R17,913 R13,840 R4,874
Above Threshold: R8,700 pb
R17,400 pf		 17,400 pf

Compare with these plans:

Consultations:
  • 12 consults paid by scheme
  • Ante-natal classes: R1,185 per pregnancy, paid from day-to-day benefit but not from above threshold
Scans:
  • 2 x 2D scans, paid by scheme

.
.

CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • Unlimited, subject to protocols
  • Biological medicine: R248,000 per family

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: R5,328 R4,146 R1,476
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive cover with savings, extended fund, and limited above threshold benefits that cover most out-of-hospital benefits (with limits).
Main: Adult: Child:
(S) Savings: R12,816 R9,936 R3,528
Extended Fund: R3,197 R2,488 R886
(SP) Self Payment: R1,900 R1,416 R460
Threshold (S+SP): R17,913 R13,840 R4,874
Above Threshold: R8,700 pb
R17,400 pf		 17,400 pf

Compare with these plans:

.
.

DENTISTRY:
Dentistry:
  • Standard dentistry: paid from day-to-day benefit, unlimited
  • Specialised dentistry: paid from day-to-day benefit, limited to R16,000 per person. Not payable from above-threshold benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,328 R4,146 R1,476
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive cover with savings, extended fund, and limited above threshold benefits that cover most out-of-hospital benefits (with limits).
Main: Adult: Child:
(S) Savings: R12,816 R9,936 R3,528
Extended Fund: R3,197 R2,488 R886
(SP) Self Payment: R1,900 R1,416 R460
Threshold (S+SP): R17,913 R13,840 R4,874
Above Threshold: R8,700 pb
R17,400 pf		 17,400 pf

Compare with these plans:

Orthodontics:
  • R17,500 per person, per lifetime
Maxillo Facial Surgery:

.
.

MEDICATION:
Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 46 conditions covered
  • non-PMBs limited to R11,100 per person and R16,700 per family
  • non-PMBs above-threshold limited to R4,175 per family, subject to sub-limits
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,328 R4,146 R1,476
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive cover with savings, extended fund, and limited above threshold benefits that cover most out-of-hospital benefits (with limits).
Main: Adult: Child:
(S) Savings: R12,816 R9,936 R3,528
Extended Fund: R3,197 R2,488 R886
(SP) Self Payment: R1,900 R1,416 R460
Threshold (S+SP): R17,913 R13,840 R4,874
Above Threshold: R8,700 pb
R17,400 pf		 17,400 pf

Compare with these plans:
Acute (presrcibed) medication:
  • Paid from day-to-day benefit
  • Limited to R3,475 per family from above-threshold
Over-the-counter:
  • R200 per event>, from day-to-day benefit
  • Limited to R920 per person and R1,310 per family
  • Not payable from above-threshold benefit, and does not accumulate to threshold
Birth Control:
  • R120 per person per month
On Discharge:
  • 7 days supply
Notes:

.
.

OPTOMETRY:
Optometry:
  • Radial keratotomy and excimer laser: R6,250 per eye. Paid by scheme
  • Otherwise, from day-to-day benefit
  • Lenses and frames: R4,175 per person
  • Frame: Sub-limit of R2,120 per person
  • Not covered by above-threshold benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,328 R4,146 R1,476
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive cover with savings, extended fund, and limited above threshold benefits that cover most out-of-hospital benefits (with limits).
Main: Adult: Child:
(S) Savings: R12,816 R9,936 R3,528
Extended Fund: R3,197 R2,488 R886
(SP) Self Payment: R1,900 R1,416 R460
Threshold (S+SP): R17,913 R13,840 R4,874
Above Threshold: R8,700 pb
R17,400 pf		 17,400 pf

Compare with these plans:

.
.

MENTAL HEALTH:
In-hospital:
  • Limited to 21 days per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,328 R4,146 R1,476
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive cover with savings, extended fund, and limited above threshold benefits that cover most out-of-hospital benefits (with limits).
Main: Adult: Child:
(S) Savings: R12,816 R9,936 R3,528
Extended Fund: R3,197 R2,488 R886
(SP) Self Payment: R1,900 R1,416 R460
Threshold (S+SP): R17,913 R13,840 R4,874
Above Threshold: R8,700 pb
R17,400 pf		 17,400 pf

Compare with these plans:


Out-of-hospital:
  • Psychiatry: R15,250 per family from day-to-day benefit
  • Psychologists: R4,570 per family from day-to-day benefit
  • Not payable from above-threshold benefit

.
.

OTHER BENEFITS:
General Appliances:
  • R31,500 per family paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,328 R4,146 R1,476
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive cover with savings, extended fund, and limited above threshold benefits that cover most out-of-hospital benefits (with limits).
Main: Adult: Child:
(S) Savings: R12,816 R9,936 R3,528
Extended Fund: R3,197 R2,488 R886
(SP) Self Payment: R1,900 R1,416 R460
Threshold (S+SP): R17,913 R13,840 R4,874
Above Threshold: R8,700 pb
R17,400 pf		 17,400 pf

Compare with these plans:

1.1. Hearing Aids:
  • See "General Appliances" limit
1.2. Wheelchairs:
  • See "General Appliances" limit
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: from day-to-day benefit but not payable from above threshold
    • 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

    .
    .

    WELLNESS/PREVENTATIVE BENEFITS:
    Flu vaccination:
    • Covered
    Overall Annual Limit (OAL):
    Unlimited overall, with sub-limits
    Contributions:
    Main: Adult: Child:
    Total Cost: R5,328 R4,146 R1,476
    Children: Pay for all children
    Day-to-Day Benefit:
    Comprehensive cover with savings, extended fund, and limited above threshold benefits that cover most out-of-hospital benefits (with limits).
    Main: Adult: Child:
    (S) Savings: R12,816 R9,936 R3,528
    Extended Fund: R3,197 R2,488 R886
    (SP) Self Payment: R1,900 R1,416 R460
    Threshold (S+SP): R17,913 R13,840 R4,874
    Above Threshold: R8,700 pb
    R17,400 pf    		 17,400 pf

    Compare with these plans:

    Pneumonia vaccines:
    • Covered, as required
    Back Rehabilitation Programme:
    Biometric Screening:
    • Covered
    Child Immunisation:
    • Covered
    Pap Smear:
    • Covered, 18yrs+
    Mammogram:
    • Covered, 35yrs+ every two years
    PAS Test:
    • Covered
      • , 40yrs+
    HIV Test:
    • Covered

    .
    .

    PROSTHESIS:
    Overal Limit:
    Overall Annual Limit (OAL):
    Unlimited overall, with sub-limits
    Contributions:
    Main: Adult: Child:
    Total Cost: R5,328 R4,146 R1,476
    Children: Pay for all children
    Day-to-Day Benefit:
    Comprehensive cover with savings, extended fund, and limited above threshold benefits that cover most out-of-hospital benefits (with limits).
    Main: Adult: Child:
    (S) Savings: R12,816 R9,936 R3,528
    Extended Fund: R3,197 R2,488 R886
    (SP) Self Payment: R1,900 R1,416 R460
    Threshold (S+SP): R17,913 R13,840 R4,874
    Above Threshold: R8,700 pb
    R17,400 pf    		 17,400 pf

    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