Sizwe Primary Care A medical aid plan: 2017

Pay for all children. Income-limited plan: R0-R530pm 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: R407 R407 R407
Children: Pay for all children
Income limit: R0-R530 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Hospital Choice:
  • Unlimited
Specialised Radiology:
  • R17,710 per family
Supplementary Services: (Physio, etc)
  • 100% scheme rate
  • Dietician, speech therapy, occupational therapy: subject to PMBs
Transplants:
Co-payments:
Alternatives to hospitals:
  • R4,310 per family

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • M =4 consults; M1 =9 consults; M2 =12 consults; M3 =14 consults etc
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R407 R407 R407
Children: Pay for all children
Income limit: R0-R530 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Day-to-day limit: M =R5,390 M1 =R7,980 M2 =R9,330 M3 =R10,670 M4 =R12,020 M5 =R13,370 M6+ =R14,720
Specialists consultations:
  • Must be referred. Limited consults to: M =2 consults; M1 =6; M2 =7; M3 =8; M4 =9; M5 =10; M6+ =11
  • Paid from day-to-day benefit
Pathology:
  • M =R1,000 and M1+ =R1,900
  • Shared with radiology benefit
  • Paid from day-to-day benefit
General radiology:
  • M =R1,000 and M1+ =R1,900
  • Shared with pathology benefit
  • Paid from day-to-day benefit
Specialised radiology:
  • R17,710 per family, in and out of hospital
Supplementary Services: (Physio, etc)
  • Physio: from day-to-day benefit
  • Otherwise: R960 per person and and R1,550 per family, paid by scheme

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MATERNITY BENEFITS:
Hospital stay:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R407 R407 R407
Children: Pay for all children
Income limit: R0-R530 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Consultations:
  • 9 consults with GP or midwife
  • 2 consults with OB, on referral
  • Paid by scheme
Scans:
  • 2 x 2D scans, paid by scheme

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • R106,500 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: R407 R407 R407
Children: Pay for all children
Income limit: R0-R530 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

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DENTISTRY:
Dentistry:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R407 R407 R407
Children: Pay for all children
Income limit: R0-R530 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Orthodontics:
Maxillo Facial Surgery:

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MEDICATION:
Chronic:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R407 R407 R407
Children: Pay for all children
Income limit: R0-R530 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Acute (presrcibed) medication:
  • Paid from day-to-day benefit, with following sub limits:
M =R1,680 M1 =R3,030 M2 =R3,370 M3 =R3,820 M4 =R3,930 M5 =R4,150 M6+ =R4,490
Over-the-counter:
Birth Control:
  • Paid from R2,490 per family
On Discharge:
Notes:

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OPTOMETRY:
Optometry:
  • Eye test: one per person every 2 years
  • Frames: R300 per person every 2 years
  • Lenses: R165 per lend for single, R360 for bifocal, R450 for multifocal, every 2 years
  • Contact lenses: R525 per person
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R407 R407 R407
Children: Pay for all children
Income limit: R0-R530 (other limits)
Day-to-Day Benefit:
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: R407 R407 R407
Children: Pay for all children
Income limit: R0-R530 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Out-of-hospital:
  • R4,190 per family

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OTHER BENEFITS:
General Appliances:
  • M =R960 and M1+ = R1,550
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R407 R407 R407
Children: Pay for all children
Income limit: R0-R530 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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1.1. Hearing Aids:
  • R5,500 per family
1.2. Wheelchairs:
  • R1,790 per family
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: R407 R407 R407
Children: Pay for all children
Income limit: R0-R530 (other limits)
Day-to-Day Benefit:
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: R407 R407 R407
Children: Pay for all children
Income limit: R0-R530 (other limits)
Day-to-Day Benefit:
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