Benefits: Hospital and Trauma

What are Hospital and Trauma benefits?

Hospital and Trauma Benefits generally cover major medical expenses that you would incur when undergoing surgery or while admitted in hospital, as well as specified procedures performed in the doctors’ rooms (see What services in doctors’ rooms are covered? below). Services not included will fall under the Everyday Services Benefits and are paid from the appropriate limit.

A visit to a hospital’s Emergency Room does not qualify to be paid from your Hospital and Trauma Benefit, unless the incident is of such a serious nature that you are admitted to a ward in the hospital itself for further treatment. You may, however, submit a motivation to the Principal Officer for consideration.

PLEASE NOTE

Various hospital groups have introduced a set of tariff codes to levy a facility fee for accessing the emergency units. If you make use of the emergency unit, a separate fee will be charged over and above the cost of treatment. The tariffs are based on the severity of the emergency admission – the higher the priority of admission, the higher the facility fee charged.

 

What is our overall annual limit?

All members have access to unlimited Hospital and Trauma Benefits at Medical Scheme Rate (MSR), no matter which Plan they belong to. There are, however, sub-limits for certain services, depending on the Plan that you are on. Refer to this detailed breakdown of the sub-limits that apply to Hospital and Trauma Benefits under the various Plans.

What services in doctors' rooms are covered?

Provided you obtain a pre-authorisation number, certain procedures that are undertaken in doctors’ rooms will be covered under your Hospital and Trauma Benefits at cost or Medical Scheme Rate, whichever is the lesser. These include but are not limited to:

  • Bone marrow biopsy
  • Colonoscopy
  • Cystoscopy
  • Functional endoscopy of sinuses
  • Upper GI endoscopy (gastroscopy)
  • Hysteroscopy
  • Intravenous therapy
  • Keloids (subject to motivation)
  • Laser to scars (subject to motivation)
  • Flexible sigmoidoscopy
  • Sclerotherapy (subject to motivation)
  • Surgical biopsies (needle biopsies) (subject to motivation)
  • Tonsillectomy (laser)
  • Vasectomy
  • Stitching of wounds
  • Excision and repair
  • Drainage of subcutaneous abscess & avulsion of nail
  • Removal of foreign body superficial to deep fascia
  • Circumcision-clamp

Any other minor surgical procedures will be considered if adequately motivated.

Contact the Call Centre to confirm whether your in-room procedure, if not listed above, is covered.

You can still authorise your treatment on the first working day after the procedure, if your circumstances do not allow you to do so beforehand. These procedures are more cost effective when performed in a doctor’s room and will be paid from the hospital and trauma benefit provided the procedure is authorised.

What treatments by a practitioner while in hospital are covered?

  • If you are diagnosed and need to be admitted to hospital, it will be to your advantage if the admitting practitioner is part of the Nedgroup GP and Specialist Network, as you will obtain cover of up to 2 x Medical Scheme Rate. In addition, you will NOT be required to make a co-payment on the hospital claim.
  • If your treating practitioner is not part of the Nedgroup GP and Specialist Network, all accounts will be covered at Medical Scheme Rate. In addition, you will be required to make a co-payment on the hospital claim (unless it was an emergency case). There will be no co-payment on the Platinum Plan, but payment will be limited to the Medical Scheme Rate.
  • If you are referred to a specialist, you should check with your administrator whether the specialist is part of the Nedgroup specialist network, as you will probably not be in a position to change your specialist at the time of requesting pre-authorisation or admission.
IMPORTANT!

If you are on any Plan other than the Hospital Network orPlatinum and you are admitted to hospital by a GP or specialist who is not on the Nedgroup network, you will incur a R2 500 co-payment.
In addition, if you are on the Hospital Network Plan and you are voluntarily admitted to a non-network hospital, you will incur a R7 000 co-payment.

 
To find out whether the practitioner is on the Nedgroup GP and specialist network, please contact Medscheme on 0860 100 080, or log onto the Member Zone.

How does pre-authorisation before hospitalisation work?

  • The purpose of pre-authorisation is not only to enable the Scheme to manage the exorbitant cost of hospitalisation, but also to ensure that our members receive the most appropriate and effective treatment available.

IMPORTANT!

You need to preauthorise any admission to hospital, or you will incur a penalty of R500 (unless it was an emergency).

 

  • Before you are admitted to hospital, other than for an emergency, you need to notify the Scheme at least three working days before the admission date. This is known as pre-authorisation.

  • It is recommended that you obtain authorisation at least ten days before being hospitalised for a procedure where an implant or an internal prosthesis will be necessary, for example, a knee replacement (quote to be provided).

  • Pre-authorisation is also required for MRI, radio-isotope and CAT scans. If you need these procedures, please follow the process in the table below.

  • If you do not inform the Scheme of a planned stay in hospital, you will be charged a penalty of R500. The Scheme could also call for medical evidence explaining why the treatment took place in hospital and reserve the right not to pay for these medical expenses.

To pre-authorise, please follow the process below (your GP/specialist or the hospital can also do this on your behalf)

  • Contact Hospital Benefit Management on 0860 100 080 (or email them three working days before being admitted to hospital (ten days for implants or internal prostheses).

  • In the case of an emergency, you must arrange to notify Medscheme on the first working day after being admitted.

  • Please make sure that you have the following information on hand when calling:

    • your membership number
    • name and date of birth of patient
    • the name and the practice number of the hospital
    • the proposed treatment or procedure/tariff code (ICD10 code) and CCSA code
    • the planned date of admission to the hospital
    • name and practice number of the doctor who wishes to admit you to hospital and
    • contact person’s details while you are in hospital
  • The consultant will confirm the benefits available for the procedure and whether your hospital admission is approved.

  • You will receive a pre-authorisation number, which the hospital will require when you are admitted. If your hospitalisation is postponed, you will need to update your pre-authorisation. If you are re-admitted to hospital, you will need to pre-authorise again.

  • If you/your dependants are scheduled to undergo an operation in the afternoon, you should ask your doctor to admit you/them after 12:00. In this way the Scheme can avoid incurring unnecessary hospital costs.

PLEASE NOTE

An authorisation is confirmation that the claims will be paid at Scheme tariff or the negotiated tariff, provided you are a registered beneficiary and your contributions are fully paid up at the time of receipt of the claims. If your provider charges more than the Scheme tariff or the negotiated tariff, you will be liable for the difference between the amount charged by the treating provider and the amount paid by the Scheme. It is recommended that you obtain a quote from the treating provider (if you select a non-network specialist) and confirm the Scheme tariff. This will enable you to negotiate with the treating provider specifically on the tariff (if you select a non-network specialist) prior to the procedure. Any shortfalls will be for your account.

 

THE PROCESS AFTER YOU ARE ADMITTED

The hospital must obtain approval from the Scheme (via the Case Manager) for stays that exceed the number of days that were initially pre-authorised.

On the day of discharge, patients should arrange to leave the hospital before 12:00. In this way the Scheme can avoid incurring unnecessary hospital costs.

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Pre-authorisation before hospitalisation
 

What services and procedures are covered during hospitalisation?

  • Services and procedures are usually covered at cost or Medical Scheme Rate (MSR), whichever is the lesser.
  • See the tables further down for the full list of the services and procedures that are covered, as well as the sub-limits that apply.
  • Any services provided in the hospital that are not related to the admitting diagnosis will not be covered (in other words, diagnostic tests not related to the reason for admission).
  • For the Scheme to consider covering the additional medical services that were not authorised or approved at pre-authorisation stage, a clinical motivation from the member or treating provider will need to be submitted to the Scheme. The request will be considered and evaluated in accordance with the Scheme’s evidence based managed care protocols and the member will be informed of the outcome. Any additional medical services which do not meet the Scheme’s evidence based managed care protocols will be for your account.

DENTISTRY

  • Hospitalisation will only be considered for basic dentistry procedures performed on beneficiaries who are 7 years or younger . In this case, the Hospital and the Anaesthetist will be paid from the Hospital and Trauma Benefit and the Dental Practitioner will be paid from the Everyday Services Benefit if your Plan has that benefit. PLEASE NOTE: A R1 500 co-payment will apply to all dental admissions. There is no cover for in-hospital dental work on the Hospital Network Plan (other than for the removal of impacted wisdom teeth, in which case a R1 500 co-payment will apply) and any such claim will be for the member’s own account.
  • All dental-related cases requiring surgery, which do not fall within the surgical class of tariffs, need to be motivated by the attending dental practitioner.
  • Orthodontic treatment for persons over the age of 21 is excluded from this benefit for all Plans.

LAPAROSCOPIC SURGERY AND OTHER SURGERIES WITH A CO-PAYMENT

  • Laparoscopic procedures are more expensive, and the procedure may in general be performed as an open procedure. The Scheme has therefore decided, like many other medical schemes, to fund these procedures with a co-payment, rather than only cover open procedures.
  • Members who undergo the following procedures will therefore be liable for the co-payments shown below (excluding PMB level of care):
PROCEDURE CO-PAYMENT
Laparoscopic hernia repair R2 500
Laparoscopic hysterectomy R2 500
Laparoscopic radical prostatectomy R2 500
Laparoscopic pyeloplasty R2 500
Knee arthroscopy R2 500
Upper GI endoscopy (gastroscopy) R500 (If performed in a doctor’s rooms, no co-payment will apply.)

 

PSYCHIATRIC SERVICES

  • This benefit covers hospitalisation and all associated accounts, for example, psychiatrist, psychologist, anaesthetist, general practitioner, occupational therapist, social worker, physiotherapist, pathology, radiology and medication.
  • It also covers consultations with a psychiatrist on an outpatient basis in the place of hospitalisation, provided that this has been pre-authorised and approved.
  • The Scheme covers a maximum of three days’ hospitalisation for beneficiaries admitted by a GP or specialist physician.
  • If a patient is not admitted to a registered psychiatric facility, the psychiatrist must arrange for a transfer to an accredited facility as soon as it is possible to do so. Alternatively the patient must be discharged.
  • A psychiatrist must assess these admissions as appropriate.
  • The Scheme does not pay for sleep therapy, since it is not recognised as therapeutic by the Association of Psychiatrists.

INTERNAL PROSTHESES

These are manufactured substitutes that are surgically implanted for a diseased or missing part of the body, or used to improve the function of a diseased or damaged organ.

PLEASE NOTE
The cost of prostheses may be more than what is covered by the Scheme, in which case you will be liable for the difference. Discuss the various alternatives with your service provider and ask for quotes that are more aligned with your benefit limit.

 

MATERNITY BENEFITS

See our Maternity Benefits chapter

How does pre-authorisation by a case manager work?

Before you receive the treatment, you need to contact the Scheme and apply for the specific benefit. This applies to the following benefits – physiotherapy following an admission, home oxygen, hyperbaric oxygen therapy and renal dialysis.

PLEASE MAKE SURE THAT YOU PROVIDE THE FOLLOWING INFORMATION TO THE CASE MANAGER:

  • your membership number
  • name and date of birth of patient
  • the proposed treatment or tariff code (ICD10 code)
  • the quotation and/or treatment plan
  • name and practice number of the doctor
  • clinical motivation

PLEASE NOTE

The Scheme may from time to time contract with or pilot with credentialed specific provider groups (networks) or centres of excellence in order to ensure cost effective and appropriate care. Beneficiaries are entitled to benefits from contracted networks appointed as the Scheme’s DSP for PMB benefits and other benefits. The Scheme reserves the right to not fund, partially fund or impose a co-payment for services acquired outside of these networks provided reasonable steps are taken by the Scheme to ensure access to the network.

 

Services and procedures covered during hospitalisation

What if I need a knee or hip replacement?

If you meet the necessary criteria on examination by the orthopaedic surgeon, you must use the Scheme’s Designated Service Providers (DSPs) for knee and hip replacements to ensure that you do not incur a co-payment for your surgery. A R10 000 co-payment will be payable by the member for the voluntary use of a non-DSP provider for hip and knee arthroplasties and/or replacement surgeries. The DSPs are ICPS (Improved Clinical Pathway Services), JointCare, Major Joints for Life (as from 1 March 2021), and Care Expert (for Platinum Plan only), groups of orthopaedic surgeons that specialise in performing hip and knee replacements according to standardised clinical care pathways. These care pathways have been developed in accordance with evidence-based outcomes to ensure that the quality of the hip and/ or knee replacement is of the highest standard and to ensure the best health outcomes. They use multidisciplinary teams dedicated to assist with rapid and successful recovery, keeping the patient as comfortable as possible during the healing period.

WHAT TO DO IF YOU NEED A HIP OR KNEE REPLACEMENT:

Hospital Network and Savings Plans only offer cover for procedures that qualify as PMB.

  • Call the Contact Centre on 0860 100 080 and you will be given the details of a DSP orthopaedic surgeon closest to you.
  • Consult with the DSP orthopaedic surgeon to see whether you meet the criteria for their clinical care pathway.
  • If you meet the criteria, an application for an authorisation number will be arranged on your behalf by the admin staff at the practice. This will ensure payment in full, with no co-payment for the procedure.

For further enquiries regarding the DSPs for hip and knee replacements, please call the Contact Centre on 0860 100 080.

(Also see the chapter Co-Payments, Penalties and Out-of-Pocket Expenses.)


The following services and procedures are covered at cost or Medical Scheme Rate, whichever is the lesser, unless otherwise stated. When multiple procedures are done, modifier 0005 is/could be applicable to the procedure (which reduces the chargeable amount); this means the treatment is paid at a sliding scale. The first procedure will be paid at Medical Scheme Rate (MSR), the second procedure at 0.75 x MSR, the third procedure at 0.5 x MSR and the fourth and subsequent procedures at 0.25 x MSR. It is recommended that you obtain a quote from your doctor (if you select a non-network specialist) and confirm the Scheme tariff. This will enable you to negotiate with your doctor to charge medical scheme rates or to give you a discount, if he or she has opted not to bill medical scheme rates. Any shortfalls for a non-network specialist (other than an emergency) will be for your account.

SERVICE CATEGORY BENEFIT
Unlimited cover for major medical expenses, subject to the pre-authorisation and case management process and, for cases over R500 000, subject to the Medical Advisor’s approval. Certain sub-limits apply.
1. Co-payments (refer to the Co-payments, Penalties and Out-of-Pocket Expenses chapter.)
  • Hospital Network Plan members or beneficiaries who are voluntarily admitted to a non-network hospital will incur a R7 000 co-payment.
  • Laparoscopic procedures listed under Laparoscopic surgery and other surgeries with a co-payment will attract a co-payment of R2 500 for all admissions, except for PMB related conditions.
  • Where the admitting doctor is not on the Nedgroup specialist network (except for emergencies), the account will attract a hospital co-payment of R2 500 (except for members on the Hospital Network or Platinum) Plan.
  • Dental admissions will attract a co-payment of R1 500 for all admissions.
2. Private and Public Hospital accommodation

To avoid incurring unnecessary hospital costs:

  • On the day of discharge, you should arrange to leave the hospital before 12:00.
  • If scheduled to undergo an operation in the afternoon, you should ask your doctor to admit you after 12:00.

Medical Scheme Rate for accommodation in:

  • a general ward
  • theatre
  • recovery rooms
  • intensive care unit
  • high care unit
  • specialised intensive care

Benefits for private or isolated wards are paid at general ward rates, unless there is an acceptable medical reason and pre-approval is obtained from the Case Manager. You will be responsible to pay the difference.

Medical Scheme Rate for operating theatres.

The benefit for nursing homes applies to registered facilities only and for short-term episodes of acute care only, in the place of hospitalisation and excludes frail care and long-term care.

Platinum Plan: Paid from Routine Medical benefit limit.

Savings and Comprehensive Plans: Paid from Personal Medical Savings Account.

Other Plans: No benefit; for member’s own account.

  • Medicine on discharge (TTO)

Limited to R830 per beneficiary per admission, and must be supplied on the day of discharge from hospital.

3. Nursing services 100% of cost with a sub-limit of R19 410 per family per year in a registered facility only and subject to pre-authorisation. This benefit covers home services by a registered nurse for short-term episodes of acute care as an alternative to hospitalisation for:

  • Wound care
  • Pre- and post-confinement treatment by a registered midwife
  • Infusions
  • Post-operative care

Only necessary medical services will be covered. Activities relating to daily living such as cooking, laundry, telephone calls and hairdressing will not be covered under this category.

4. Prescribed Medication
(Nursing homes/Hospice)

Medication provided may be covered from either the Everyday Services Benefits, or Personal Medical Savings Account, where applicable. Prescribed (acute) medicines will not be covered on the Hospital Network Plan, except for Major Depression and those conditions covered under Prescribed Minimum Benefits.

PLEASE NOTE: You must apply for this benefit and it must be pre-authorised by the Case Manager.

5. Hospices

Cost or Medical Scheme Rate, whichever is the lesser, limited to R35 960 per family per year.

The medication will be subject to your Prescribed medicine (acute) sub-limit.

6. Maternity

  • Confinement in hospital

Cost or Medical Scheme Rate, whichever is the lesser, subject to the overall annual limit.

As per clinical guidelines and protocols.

Further days will require motivation by the attending doctor and approval by a Case Manager.

  • Midwife delivery

Society for Private Nurse Practitioners’ tariffs, including pre-and-post confinement costs, if a gynaecologist is not used.

  • Confinement in a registered birthing unit

Cost or Medical Scheme Rate, whichever is the lesser, subject to the overall annual limit.

Including 4 x post-natal midwife consultations per event.

7. Ambulance services

Tariff agreed with the Scheme’s preferred provider, ER24.

8. General practitioners & medical specialists in hospital

The Scheme has appointed a Nedgroup GP and Specialist Network as our Designated Services Provider. If you are referred to a specialist, please check with your administrator whether the specialist is part of the Nedgroup Specialist Network.

Scheme negotiated tariff for a network specialist or Medical Scheme Rate for the specialist who is not part of the Nedgroup Specialist Network for the following services:

  • surgery
  • procedures in hospital
  • anaesthesia
  • applicable portion of assistant’s fees at operations
  • hospital visits
  • Dental practitioners in hospital

Platinum Plan: Paid from Routine Medical Benefit limit
Comprehensive Plan: Paid from Everyday Services Benefit limit
Traditional Plan: Paid from Everyday Services Benefit limit
Savings Plan: Paid from Personal Medical Savings Account
Hospital Network Plan: No benefit; for member’s own account, except for the removal of wisdom teeth, which are covered from the overall annual benefit.

9. Radiology and Pathology

  • General Radiology and Pathology (in hospital)

Medical Scheme Rate subject to the overall annual limit.

  • Specialised Radiology (in and out of hospital)

    MRI scans, radio-isotope scans and CAT scans (wherever the service is provided – excluding PET scans), subject to pre-authorisation.

Medical Scheme Rate up to a maximum of R19 730 per family per year.

  • Ultrasound scans (in and out of hospital – other than pregnancy scans)

Medical Scheme Rate up to a maximum of R7 600 per family per year.

10. Maxillofacial and oral surgery

PMB only

11. Dental implants or Building up of Teeth

(In and out of hospital)
On the Comprehensive, Traditional and Savings Plans a R1 500 co-payment will apply for in-hospital procedures.

Hospital Network Plan: No benefit; for member’s own account.

Savings Plan: Paid from Personal Medical Savings Account

Platinum, Comprehensive and Traditional Plans: Medical Scheme Rate, with a sub-limit of R16 670 per family per year for the cost of implant placements and implant components or the building up of a tooth.

PLEASE NOTE: The building up of a lost tooth refers to the actual implant and implant components. The structure that is placed on the implant refers to the crown – in this case the implant-supported crown. A crown is categorised as advanced dentistry and will therefore be payable from your available Everyday Services Benefits.

Hospital-related costs such as accommodation, specialist fees, theatre fees as well as associated services are subject to the normal Hospital and Trauma Benefit limits.

A dental treatment plan will be required for every phase of treatment and needs to be submitted to the Scheme and approved before the procedure.

12. Orthognathic surgery

(Functional correction of malocclusions)

Platinum, Comprehensive, and Traditional Plans: Limited to and included in the overall annual limit.

Savings Plan: Paid from Personal Medical Savings Account.

Hospital Network Plan: No benefit; for member’s own account.

Includes all services rendered, including the cost of special investigations, hospitalisation, all general and specialist dental practitioners, their assistants and anaesthetists as well as the cost of materials, all implant components, plates, screws and bone or bone-equivalent in respect of the orthognathic surgery procedure.

13. Physiotherapy

  • In hospital.

Cost or Medical Scheme Rate, whichever is the lesser, subject to the overall annual limit.

  • After hospitalisation, if linked to the hospital admission.

Cost or Medical Scheme Rate, whichever is the lesser. This benefit must be pre-authorised by the Case Manager before discharge from hospital. It is limited to a maximum of ten appointments and treatment within 30 days of discharge from hospital or within a reasonable period of discharge.

14. Physical Rehabilitation

Medical Scheme Rate with a sub-limit of R82 480 per family per year, subject to approval by the Case Manager. This benefit will only be allowed for the following non-progressive conditions: acute disablement as a result of a stroke, spinal cord injury or brain injury (where injury refers to a lesion relating to the above only and is caused by trauma, infection, surgery, bleeding or infarction). This benefit includes all associated accounts.

15. Mental health

  • Psychiatric treatment

Negotiated tariff up to a maximum of 21 days per beneficiary per year or outpatient psychotherapy, up to 15 days’ contact sessions. This benefit is subject to pre-authorisation. This benefit covers all related costs.

  • Treatment and accommodation for substance abuse

Negotiated tariff up to a maximum of 21 days per beneficiary per year. This benefit is subject to pre-authorisation. This benefit covers all related costs.

16. Oncology

  • (Including approved, related medication, MRI, CAT and radio-isotope scans as well as chemotherapy, radiotherapy, oncologists’ consultations, mammograms, radiology and pathology fees)

The Scheme has appointed the Nedgroup Oncology Network and Pharmacy Direct as our Designated Service Providers for oncology. If you are referred to a provider for oncology related treatment, please check with your administrator whether the provider is part of the Nedgroup Oncology Network.

Medical Scheme Rate for non-DSP, or negotiated tariff for DSP, with the following sub-limits, provided the patient enrols on the Oncology Benefit Management Programme.

Platinum, Comprehensive, and Traditional Plans: R677 590 per family per year (with ICON Enhanced Protocols)

Savings and Hospital Network Plans: PMB only (with ICON Standard Protocols)

A 12-month care plan must be submitted to the Case Manager, and is subject to approval by the Case Manager in terms of the Scheme’s managed care protocols for the diagnosis. The care plan should include the date of diagnosis, the area concerned, any prior surgery or treatment, new treatment requests, as well as approximate costs.

  • The cost of a mammogram will be covered if it forms an integral part of the care plan, submitted by your oncologist.

  • Vitamins, antibiotics, alternative medicine, sleeping tablets, anti-anxiety and medicines for depression will not be covered.

  • Medicines must be registered with and approved by the South African Health Products Regulatory Authority for the specific diagnosed condition.

Platinum, Comprehensive and Traditional Plans: Herceptin 12-month course of treatment will be covered as per clinical protocols and guidelines for adjuvant treatment of early breast cancer.

Limited to and included in the Oncology benefit during the remission period following the active treatment period.

  • Social worker – Oncology treatment

Medical Scheme Rate or cost, whichever is the lesser, for consultations with a social worker, up to a sub-limit of R3 390 per family per benefit year on referral from the Nedgroup Oncology Network for terminal cases.

  • PET scans

Medical Scheme Rate with a sub-limit of R34 240 per family per year, subject to the approval of the Case Manager.

  • Brachytherapy

    (Including seeds, disposables and equipment. Subject to the Oncology Managed Healthcare Programme.)

Medical Scheme Rate with a sub-limit of R51 720 per family per year.

  • Specialised drugs for Oncology

    (Subject to the relevant managed healthcare programme and to its prior authorisation. The Oncology Specialised Drug List is a continuously evolving list of drugs used for the treatment of cancers and certain haematological conditions. This list includes but is not limited to targeted therapies, for example, biologicals, tyrosine kinase inhibitors and other non genericised chemotherapeutic agents. Subject to a published list.)

Platinum, Comprehensive, and Traditional Plans: Medicine price with a sub-limit of R228 870 per year, subject to the Overall Oncology Benefit (with ICON Enhanced Protocols).

Savings and Hospital Network Plans: PMB only (with ICON Standard Protocols)

A member on the Hospital Network or Savings Plans will have the choice to upgrade to a plan with enhanced Oncology benefits within 60 days of the member or one of his/her dependants being diagnosed with cancer or having to undergo Oncology treatment. Any request to upgrade after 60 days will require motivation and approval by the Scheme.

Pharmacy Direct is the Designated Service Provider for specialised drugs for oncology.

17. Non-Oncology specialised drugs

(The non-oncology specialised drug list is a continuously evolving list of high cost drugs used for the treatment of chronic conditions. This list includes but is not limited to biological drugs (biological therapy for inflammatory arthritides, inflammatory bowel disease, chronic demyelainating polyneuropathies, chronic hepatitis, botulinum toxin, palivizumab). Unless otherwise stated, for any other diseases where the use of the drug is deemed appropriated by the managed health care organisation, drugs will be funded from this benefit. Subject to a published list.)

Platinum, Comprehensive, and Traditional Plans: Medicine price with a sub-limit of R205 490 per family per year, subject to application and approval under the Scheme’s managed care protocols.

Savings and Hospital Network Plans: PMB only

Pharmacy Direct is the Designated Service Provider for non-oncology specialised drugs.

18. Macular degeneration drugs

Platinum, Comprehensive, and Traditional Plans: Medicine price with a sub-limit of R64 560 per family per year, subject to a motivation received from the provider and subsequent approval.

Savings and Hospital Network Plans: PMB only

19. Blood transfusions

Cost or Medical Scheme Rate, whichever is the lesser (cost of material, apparatus and operator’s fee).

20. Perfusion services

Cost or Medical Scheme Rate, whichever is the lesser (cost of material, apparatus and clinical technologist’s fee).

21. Organ Transplant/donor services

Cost, subject to Prescribed Minimum Benefits

  • Organ transplant

Proposed transplants need to be pre-authorised. An application, together with the relevant treatment plan, which the patient must obtain from his/her doctor, should be submitted, after which the relevant Case Manager will contact the patient.

Medicine price for anti-rejection drugs, subject to pre-authorisation, provided that drugs from a preferred provider are used.

  • Organ donors

Subject to pre-authorisation, the benefit is only available to live donors who are beneficiaries of the Scheme. A donor belonging to the Scheme will also be covered when donating to a recipient who is not a member of the Scheme.

22. Corneal grafts

Cost, limited to R36 190, subject to the relevant managed healthcare programme and to pre-authorisation, as well as approval by the Scheme before starting work-up for transplantation. Associated costs are covered from the Overall Annual Limit.

23. HIV Benefit

Benefits are unlimited, subject to approval for medication and medical management.

Mother-to-child, accidental exposure and rape-prophylactics must be pre-authorised by the HIV Care Manager.

For a rape case, the hospital will provide a three-day “starter kit” of anti-retroviral treatment, which will fall under the HIV limit. If this medication is required for a further 28 days, the additional benefit needs to be pre-authorised by the Care Manager.

  • HIV Testing

It covers the following services:

  • Pre-testing counselling
  • Testing and post-test counselling

24. Internal prostheses (devices surgically implanted)

Including all accompanying temporary or permanent devices used to assist with the guidance and alignment of these internal prostheses and devices. Patients may pre-authorise 10 working days prior to admission for a joint replacement or spinal fusion operation.

ICPS (Improved Clinical Pathway Services), JointCare, Major Joints for Life (as from 1 March 2021), and Care Expert (for Platinum Plan only) are the Scheme’s DSPs for hip and knee replacement. They are groups of orthopaedic surgeons that specialise in performing hip and knee replacements according to standardised clinical care pathways, for knee and hip replacements. These care pathways have been developed in accordance with evidence-based outcomes to ensure that the quality of the hip and/or knee replacement is of the highest standard and to ensure the best health outcomes. Call us on 0860 100 080 and ask for the details of a DSP orthopaedic surgeon closest to you.

Cost for specific prosthesis applied for, subject to the relevant managed healthcare programme and to prior authorisation. The following specific sub-limits apply per beneficiary per year (unless stated otherwise):

Cardiac system:

  • Cardiac pacemakers: R83 240 per beneficiary per year
  • Cardiac stents (including the carrier) and drug eluting-balloons. R34 610 per stent per beneficiary, limited to 3 x stents
  • Cardiac valves: Limited to R49 020 per valve per year, limited to 2 x valves.
    On the Platinum, Comprehensive, and Traditional Plans, inoperable patients who meet the required criteria may qualify for Transcatheter Aortic Valve Implementation (TAVI) to the value of R236 570.
  • Cardiac Resynchronisation Therapy (CRT): R57 520

Central nervous system:

  • Neuro-stimulation (ablation devices for Parkinson’s): R54 810
  • Vagal stimulator (for intractable epilepsy): R46 250

Endovascular devices:

  • Aorta stent grafts: R142 400 per stent (including the delivery system), limited to 1 stent
  • Carotid stents: R24 150
  • Detachable platinum coils: R60 110
  • Embolic protection devices: R59 940
  • Endovascular aneurysm repair (EVAR) stent grafts: R155 100
  • Peripheral arterial stent grafts: R49 650

Orthopaedic prostheses and devices including cement and antibiotic cement:

  • Elbow replacements: R53 100 per elbow
  • Total hip replacement: R62 910 per hip
    Hospital Network and Savings Plans PMB only
  • Total knee replacement: R69 550 per knee
    Hospital Network and Savings Plans PMB only
  • Total shoulder replacement: R60 490 per shoulder
  • Spinal instrumentation: R74 770
  • Bone lengthening devices: R53 930
  • Other approved spinal implantable devices and intervertebral discs: R60 110

Opthalmic system:

  • Intraocular lenses: R3 840 per lens, limited to 2 lenses

Any other prostheses not listed above:

  • R67 530, subject to Case Management approval.

The following prostheses are also covered by the Scheme:
Cables, Plates: screws, orthopaedic staples, K-wires and rods, Staples (bones), Exo-skeletal apparatus, Cardiac and rings, Silicone bands (intra-ocular surgery), Ventriculo-peritoneal/Pleural shunt, Tension-free vaginal tapes/slings, Coral implants, Bone Cement, Aortic grafts, Artificial sphincter (M), Aortic modular stents (M), Hepatic stents, Breast prosthesis (M). The items above indicated by an “M” must be motivated by a medical practitioner.

25. All refractive procedures

(Including Lasik, radial keratotomy, and phakic lenses)

Cost or Medical Scheme Rate, whichever is the lesser.

Platinum, Comprehensive and Traditional Plans: R15 810 per family per year for hospital and associated services. Hospital related costs such as accommodation and theatre fees, as well as associated services, are subject to this limit. Benefits will only be granted if medical reports, as required by the Scheme, are submitted to prove that this operation is necessary, based on medical grounds and within the set refraction limit of the Scheme’s guidelines.

Platinum Plan: Once this limit has been exceeded, claims will be paid from the Routine Medical Benefit.

Savings Plan: Paid from Personal Medical Savings Account.

Hospital Network Plan: No benefit; for member’s own account.

26. Artificial limbs and artificial eyes

Cost according to clinical protocols, subject to the relevant managed healthcare programme and to the following sub-limits:

  • R86 570 per artificial leg per beneficiary (every 2-3 years for children and every 5 years for adults)
  • R86 570 per artificial arm per beneficiary (every 2-3 years for children and every 5 years for adults)
  • R30 180 per artificial eye per beneficiary (every 2-3 years for children and every 5 years for adults)
  • R14 780 per artificial iris per beneficiary per year (every 2-3 years for children and every 5 years for adults)

27. Renal dialysis

(Including related pathology, scans and consultations.)

Cost or Medical Scheme Rate, whichever is the lesser

Savings and Hospital Network Plans: PMB only

PLEASE NOTE: A 12-month treatment plan must be submitted to the Case Manager and is subject to approval in terms of the Scheme’s managed care protocols. This plan should include the following information:

  • date of diagnosis
  • area concerned
  • any prior surgery or treatment
  • ICD10 code
  • tariff code
  • doctor’s practice number
  • new treatment requested
  • the approximate cost

Subject to pre-authorisation for the related medication from a preferred provider.

28. Home oxygen therapy

(Subject to the relevant managed healthcare programme and pre-authorisation.)

Platinum, Comprehensive and Traditional Plans: Unlimited at cost or Medical Scheme Rate, whichever is the lesser.

Savings and Hospital Network Plans: Cost with a sub-limit of R20 370 per family per year.

PLEASE NOTE: You must apply for this benefit and it must be pre-authorised by the Case Manager.

29. Hyperbaric oxygen therapy

Cost or Medical Scheme Rate, whichever is the lesser with a sub-limit of R66 580 per family per year.

PLEASE NOTE: This benefit must be motivated by a specialist and pre-authorised by the Case Manager. It will not be approved for the treatment of strokes, cerebral palsy, diabetic wounds and ulcers. The therapy is used to treat arterial gas embolism, carbon monoxide poisoning, crush injuries, thermal burns and many other conditions.

30. Stoma care products

Cost with a sub-limit of R23 690 per family per year.

31. Breast reduction

Cost or Medical Scheme Rate, whichever is the lesser.

Subject to submission of a motivation by the treating provider and submission of medical reports as required by the Scheme. Benefits are subject to approval of the procedure by the Scheme’s medical advisor on the grounds that patient meets the clinical criteria (such as Body Mass Index) applied by the Scheme in terms of the Scheme’s managed care protocols.

32. Cochlear implants

R260 570 per implant

Subject to one implant per beneficiary per ear for life.

R130 280 maintenance or replacement of processors per beneficiary every 5 years

 

PLEASE NOTE

All hospitalisation is subject to the Scheme’s contracted managed healthcare programmes, which include the application of treatment protocols, formularies, pre-authorisation and case management.

The Scheme reserves the right not to pay for procedures performed by non-recognised providers (where applicable).

Certain procedures may be associated with a significant learning curve and/or are not taught routinely at local universities and/or require special training and experience, including that aimed at maintenance of expertise, and/or need access to certain infrastructure for quality outcomes. Where such procedures have been identified by the Scheme’s managed care provider, recognised providers are those who have been acknowledged by meeting minimum training and practice criteria for the safe and effective performance of such procedures. Recognition occurs as a result of a formal application process by interested providers and adjudication of relevant information against competency guidelines by the managed care provider and/or appointed credentialing body. Criteria for formal recognition are informed by clinical evidence, clinical guidelines and/or expert opinion.

The Scheme (or contracted managed care company on behalf of the Scheme) may from time to time contract with credential specific provider groups (networks) or centres of excellence as determined by the Scheme in order to encourage high-quality, cost effective and appropriate care. The Scheme reserves the right not to fund or partially fund services acquired outside of these networks, provided reasonable steps are taken by the Scheme to ensure access to the network.

 

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