Sizwe Gomomo B medical aid plan: 2017

Out-of-hospital, scheme pays for some: GPs, specialists, medication, radiology, physio, pathology, standard dentistry, optometry, maternity. Limits apply. All else paid from out of pocket, unless PMB. Pay for all children. Income-limited plan: R10,113+pm only

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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: R2,060 R1,623 R420
Children: Pay for all children
Income limit: R10,113+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medication, radiology, physio, pathology, standard dentistry, optometry, maternity. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Hospital Choice:
  • Network
Specialised Radiology:
Supplementary Services: (Physio, etc)
  • 100% scheme rate
  • Dietician, speech therapy, occupational therapy: subject to protocols
Transplants:
  • Unlimited, at PMB level of care
Co-payments:
Alternatives to hospitals:

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Chosen GP: Unlimited if pre-authorised
  • Other GP: 4 consults if pre-authorised
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,060 R1,623 R420
Children: Pay for all children
Income limit: R10,113+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medication, radiology, physio, pathology, standard dentistry, optometry, maternity. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Specialists consultations:
  • Covered if referred by GP
Pathology:
  • No benefit, unless PMB
General radiology:
  • No benefit, unless PMB
Specialised radiology:
  • R6,770 per family, in and out of hospital
Supplementary Services: (Physio, etc)
  • R2,400 per family

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MATERNITY BENEFITS:
Hospital stay:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,060 R1,623 R420
Children: Pay for all children
Income limit: R10,113+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medication, radiology, physio, pathology, standard dentistry, optometry, maternity. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Consultations:
  • Subject to DSP and pre-authorisation
  • Paid by scheme
Scans:
  • 2 x 2D scans, paid by scheme

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • 100% scheme tariff

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: R2,060 R1,623 R420
Children: Pay for all children
Income limit: R10,113+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medication, radiology, physio, pathology, standard dentistry, optometry, maternity. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

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DENTISTRY:
Dentistry:
  • Standard dentistry:
M =R2,630 M1 =R3,030 M2 =R3,290 M3 =R3,560 M4 =R3,810 M5 =R4,070 M6+ =R4,470
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,060 R1,623 R420
Children: Pay for all children
Income limit: R10,113+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medication, radiology, physio, pathology, standard dentistry, optometry, maternity. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Orthodontics:
  • No benefit
Maxillo Facial Surgery:

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MEDICATION:
Chronic:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,060 R1,623 R420
Children: Pay for all children
Income limit: R10,113+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medication, radiology, physio, pathology, standard dentistry, optometry, maternity. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Acute (presrcibed) medication:
  • No benefit
Over-the-counter:
  • R280 per family
Birth Control:
  • No benefit
On Discharge:
Notes:

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OPTOMETRY:
Optometry:
  • Subject to DSP and protocols. Paid by scheme
  • M =R1,080 M1 =R1,240 M2 =R1,370 M3 =R1,970
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,060 R1,623 R420
Children: Pay for all children
Income limit: R10,113+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medication, radiology, physio, pathology, standard dentistry, optometry, maternity. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
  • 21 days per person
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,060 R1,623 R420
Children: Pay for all children
Income limit: R10,113+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medication, radiology, physio, pathology, standard dentistry, optometry, maternity. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:


Out-of-hospital:
  • Subject to pre-authorisation and managed care

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OTHER BENEFITS:
General Appliances:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,060 R1,623 R420
Children: Pay for all children
Income limit: R10,113+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medication, radiology, physio, pathology, standard dentistry, optometry, maternity. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

1.1. Hearing Aids:
1.2. Wheelchairs:
Dialysis:
HIV:
  • Subject to treatment protocols
Emergency Transport: Europ Assist
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: R2,060 R1,623 R420
Children: Pay for all children
Income limit: R10,113+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medication, radiology, physio, pathology, standard dentistry, optometry, maternity. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Pneumonia vaccines:
Back Rehabilitation Programme:
Biometric Screening:
Child Immunisation:
Pap Smear:
Mammogram:
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: R2,060 R1,623 R420
Children: Pay for all children
Income limit: R10,113+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medication, radiology, physio, pathology, standard dentistry, optometry, maternity. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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