Plus Option
Hospitalisation Benefits
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Effective 1 January 2024
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Members and their dependants are entitled to the following benefits, subject to the provisions of the rules of the Scheme, and in particular the provisions of the statutory Prescribed Minimum Benefits (PMBs).
This summary is for information purposes only and does not supersede the rules of the Scheme. In the event of any discrepancy, the rules will prevail.
| Benefits | Description | |
|---|---|---|
| Statutory Prescribed Minimum Benefits (PMBs) | Services rendered by State hospital or DSP unlimited, subject to pre-authorisation and managed care protocols | 100% of cost |
| Hospitalisation | Unlimited Admissions are subject to pre-authorisation with the Scheme's provider 2 working days prior to admission and within 48 hours of the incident in the case of emergencies A penalty of R1 000 is payable by the member to the service provider if no pre-authorisation is obtained; for pre-authorisation dial 0860 767 633 |
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| Private hospitals (excluding rehabilitation) |
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100% of Agreed Rate |
| State hospitals |
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100% of UPFS or cost, whichever is the lowest |
| Medicines dispensed in and upon discharge from hospital |
To take out medicines (TTOs) are limited to a 7 day supply and are subject to medicine formulary |
100% of SEP and agreed dispensing fee |
| Alternatives to hospitalisation (i) Step-down facilities (ii) Hospice (ward fees and disposables) (iii) Home nursing |
Subject to PMB regulations, pre-authorisation and managed care protocols |
100% of Agreed Rate or 100% of cost in the case of a PMB |
| In-patient psychiatric conditions/substance abuse | R78 600 per beneficiary for non PMB's. PMB admissions will accrue to this limit, but are not subject to this limit |
100% of Agreed Rate |
| General Practitioner Procedures and Consultations Consultations, visits and procedures/operations |
Unlimited |
140% of Scheme Rate |
| Specialist Procedures and Consultations |
Unlimited |
100% at a Preferred Provider Specialist 140% of Scheme Rate at a non-preferred provider. Co-payments may apply at a non-preferred provider |
| Radiology In-hospital |
Unlimited |
100% of Scheme Rate |
| Specialised radiology (MRI and CT scans) | Subject to pre-authorisation Unlimited PMB scans per family per year Limited to 2 non-PMB scans per family per year; subject to R500 co-payment |
100% of Scheme Rate or Agreed Rate |
| Pathology | Unlimited | 100% of Scheme Rate or Agreed Rate |
| Auxiliary services Physiotherapy, audiology and occupational therapy |
Subject to pre-authorisation and managed care protocols and only if part of a hospital event or following discharge for a period of six weeks | 100% of Scheme Rate |
| Blood transfusions and technician services |
Unlimited |
100% of Scheme Rate or Agreed Rate |
| Oncology treatment (in and out of hospital) | R710 000 per beneficiary Subject to pre-authorisation and registration on the Oncology Management Programme Contact: 0860 767 633 Subject to ICON protocols |
100% of Agreed Rate at a Preferred Provider 140% of Scheme Rate at a non-Preferred Provider. Co-payments may apply at a non-Preferred Provider |
| Surgical/Internal prostheses |
Limited to amounts detailed in the surgical prostheses schedule (Annexure B) for specified items |
100% of Agreed Rate per item as per Annexure B |
| Maxillofacial surgery (excluding specialised dentistry) |
Subject to pre-authorisation and managed care protocols |
100% of Scheme Rate |
| Organ transplants (hospitalisation and surgery) |
Subject to pre-authorisation and managed care protocols |
100% of Agreed Rate at preferred provider 140% of Scheme Rate at a non-preferred provider; co-payments may apply at a non-preferred provider |
| Emergency rescue services: ER24 | Subject to pre-authorisation and ER24 protocols; tel: 084 124 | 100% of Agreed Rate 100% of cost in the case of a PMB |
| HIV/AIDS |
For access to the HIV/AIDS benefit, registration is required on the HIV Management Programme |
100% of cost |
| Renal dialysis |
Subject to pre-authorisation and managed care protocols |
100% of Agreed Rate 100% of Agreed Rate in the case of a PMB |
| Out-patient surgical procedures If performed in a doctor's surgery subject to pre-authorisation and managed care protocols
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Covered from insured benefit Subject to pre-authorisation and managed care protocols Anaesthetists' costs, if applicable, are covered for local/regional anaesthetic and conscious sedation |
100% of the Agreed Rate at a Preferred Provider Specialist 140% of Scheme Rate at a non-preferred Provider. Co-payments may apply at a non-Preferred Provider |
The following additional procedures, if performed by an ophthalmologist in his/her rooms
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Subject to pre-authorisation and managed care and funding protocols Covered from the insured benefit Costs related to Lasik eye surgery are excluded from the benefit. |
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| Circumcision Refer to Annexure A for the tariff codes per procedure |
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| Emergency room treatment: In a trauma or casualty facility of a hospital |
All associated costs, where the treatment resulted in an admission to hospital, or was an emergency, or prevented a hospital admission, or where treatment could not be rendered in a doctor's rooms | 100% of Agreed Rate and/or 140% of Scheme Rate, or at cost for PMBs |