Benefits Guide - · PDF fileSizwe Medical Fund - Benefits Guide pg 3 Sizwe History 2018 Offerings Hospital Care Gomomo Care Primary Care Affordable Care Full Benefit Care Sizwe History

Benefits Guide - 2018

pg 2 Sizwe History

A Brief history of Sizwe Medical Fund and Sechaba Medical Solutions

In the late 1960s, Black (African) doctors in the Rand, which consisted of Johannesburg, Pretoria, the Eastrand, and Vereeniging, formed themselves into “ The S. A. Medical Discussion Group” (SAMDG) which discussed matters of interest to Black doctors and their patients. The South African Medical Association was only open to white membership then.

The SAMDG met once a month on a Sunday afternoon. Meetings were hosted by members at their homes. Spouses attended meetings and held their own meeting whilst members discussed the business of the day. Meetings ended with a social. The executive of the SAMDG was appointed by region to facilitate executive meetings, in 1976, the executive was from the Eastrand, it was chaired by Dr. Mzamane of Katlegong.

It was in 1976 that Dr. Mokgesi who had a practice in Sebokeng, met a white colleague, Dr. Loots at a clinical meeting at the Joburg Gen. Dr. Loots suggested that it would be a good thing to register a medical aid scheme for blacks and a private hospital for blacks, he would introduce the matter to some government officials who would make the registering of a black company in the urban areas possible as this was not permissible then.

The matter of a medical aid scheme and a private hospital for blacks was discussed by the SAMDG and accepted. Dr. Motlana, who was very influential in black circles and highly respected by business leaders and politicians of all sectors of S African society took up leadership of the group, he led the selling of the idea to black doctors to take up shares, negotiated with white business to support the initiative, and served as chairman of the group. At this time, Dr. Motlana also led various committees of the STRUGGLE which took a great deal of his time and resulted in him spending many months under detention.

In 1978 The Kwacha Group was registered with 38 shareholders. Dr. Loots was the only white shareholder. He also served on the board of directors. Sizwe Medical Fund was registered, the 38 shareholders raised R3 000 000 as security to meet claims. Lesedi Clinic was to open its doors soon after Sizwe started. (Kwacha meaning ‘Day Break’ in Chewa was chosen as an appropriate name for the new company). Kwacha was later changed to Sechaba Group Holdings (Pty)Ltd

Sizwe Medical Fund - Benefits Guide 2018 pg 3

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A Brief history of Sizwe Medical Fund and Sechaba Medical Solutions

The motivation for forming the Kwacha Group

• To provide medical aid cover for blacks;• To enable black specialists to open private practice, black specialists of the day could only

work as GPs with specialist qualifications, as specialist fees were only affordable to medical aid members. Black specialists who worked in public hospitals were not recognised, they were humiliated as they could not give orders to white juniors and to white nurses of all ranks! Many black specialists elected to go into exile and practice in the USA and in Canada.

• To give black private patients and their doctors access to Xray, other investigations and expensive medications which were out of reach for virtually all who had no medical aid cover.

• To lead the black population in matters of healthcare.

Although Dr. Motlana tried to persuade the powers that be to allow black civil servants of the day to join Sizwe, the government refused, and instead registered Bonitas for black civil servents, Sanitas for Indians, and Prosano for coloured civil servents. All these schemes were to be administered by Medscheme this is certainly the reason for Bonitas being the second largest open scheme in S.A today.

The first members of Sizwe were drawn from the Barlow Rand Group, from Iscor, from PUTCO and from the steel companies and coal mining companies in Witbank and Middleburg as well as motor industry workers from Port Elizabeth and Uitenhage. The initiative by our founding fathers has survived to this day!!

Dr Tlakula

pg 4 2018 Healthcare Offerings

HOSPITAL CARE PRIMARY CAREGOMOMO CARE

The Hospital Care Option offers peace of mind knowing that in the event of hospitalisation, extensive cover is available at any private hospital.

In addition, the Hospital Care Option provides cover for 27 Chronic Disease List (CDL) conditions.

Primary Care Option offers good value for money with unlimited hospitalisation at any private hospital.

This traditional option has generous day-to-day benefitswhich cover acute medicines GPs,specialists, radiology, pathology and more to meet the needs of any family.

This is our entry-level option. Gomomo Care Option provides excellent value for money. GPs, specialists and acute medicines are accessible through a selected network provider Dentistry, radiology and pathology are also available from a network provider.

No overall limit for hospitalisation at any private hospital. Covers the 27 Chronic Disease List (CDL) conditions.

2018 HEALTHCARE

pg 4 2018 Healthcare Offerings - Subject to CMS approval


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2018 Offerings

FULL BENEFIT CARE

Our Full Benefit Care Option offers comprehensive cover and generous benefits to cover families and individuals who need access to unlimited hospitalisation at any private hospital.

This option also offers additional chronic conditions, specialised dentistry, GPs, specialists, acute medication, preventative care benefits and more rich benefits. This is the only option which offers Top-up cover when in hospital up to 200% of the Sizwe rate.

AFFORDABLE CARE

Our Affordable Care Option offers generous comprehensive cover with unlimited hospitalisation in any private hospital.

It also covers additional chronic conditions with specialised dentistry and preventative benefits.

This option is suitable for young and healthy families.

OFFERINGS

Sizwe Medical Fund - Benefits Guide 2018 pg5

pg 8 Hospital Care

HOSPITAL CAREOffers peace of mind

knowing that in the event of hospitalisation, extensive

cover is available at any private hospital.


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IN-HOSPITAL BENEFITS(All hospital admissions must be authorised.

A co-payment of R1 500 will be applied if pre-authorisation was not obtained)

AUXILIARY SERVICES

General 100% Sizwe rate

Dietician, speech therapy, occupational therapy

Subject to PMB, clinical protocols and pre-authorisation

PHYSIOTHERAPY

Reimbursement RatePre-authorisation and managed care protocols apply

100% Sizwe Rate

OUT OF HOSPITAL BENEFITS

Option Structure Major Medical; Day to day: Risk

OVERALL DAY-TO-DAY LIMIT

Benefit No benefit

GENERAL PRACTITIONERS

Reimbursement rate No benefit

SPECIALISTS (excluding psychiatrists), Acute Medicine,

Pathologists,Radiologists And Physiotherapists


Benefits Only PMBs

ACUTE MEDICINES AND PHARMACY ADVISED THERAPY (PAT) - FALLS WITHIN DAY-TO-DAY BENEFIT WITH THE

FOLLOWING SUB-LIMITS


RADIOLOGY AND RADIOGRAPHY

General Reimburse-ment rate No benefit

Specialist Reimburse-ment rate No benefit

PHYSIOTHERAPY


PATHOLOGY


BASIC DENTISTRY


SPECIALISED DENTISTRY


OPTICAL BENEFITS ACCESSED THROUGH PPN


MENTAL HEALTH


AUXILIARY SERVICES(Chiropractic Treatment, Homeopathy)


MATERNITYSubject to registration on the Sizwe Baby Programme within

24 weeks of falling pregnant

Reimbursement rate 100% Sizwe rate

Ante-natal consultationsAnte-natal consultation: 9 GP, Midwife Visits2 Obstetrician visits

Pregnancy scans and blood tests

2 x 2D scansBlood tests:• Two (2) Haemoglobin Measurement tests, • One (1) Blood Grouping test, • One (1) VDRL test for Syphilis and • One (1) HIV blood test

Fertility No benefits

PSYCHOLOGICAL AND PSYCHIATRIC TREATMENT


MEDICATION

Acute Reimburse-ment rate No benefits

OTC Reimburse-ment rate No benefits

CHRONIC CONDITIONS

PMB 100% negotiated tariff at Preferred Provider Network

Non-PMB No benefit

Limits Formulary, limit per family

Overall limits (Annual)

PrincipalMSA

Risk benefit per family

Adult MSA

Child MSA



Overall annual limit Unlimited

Provider Network Any

BENEFITS

Top-up cover No benefit

Co Payments

General scopes R1 300

Endoscopic (Laparoscopic surgery) investigations

R3 000

AMBULANCE SERVICESContracted EUROP ASSISTSA (Telephone number:0860 11 77 99

100% Sizwe rate

PRIVATE HOSPITALS AND NURSING HOMES(Subject to treatment and case management protocols

and PMBs. Pre-authorisation required unless it is a medical emergency)

Accommodation Unlimited at any private hospital


Clinical limitations and exclusions None

DENTISTRY(Subject to Dental Management Programme -

call 0860 109 556)

Conservative Dentistry

Reimbursement rate

100% Sizwe rate

Subject to pre-autho-rised and managed care protocols

Specialised Dentistry(Subject to pre-authorisation and Dental

Management Programme)


Crowns and Bridges No benefit

Orthodontics (Braces) No benefit

Implants No benefit

Partial Metal Frame Dentures No benefit

Surgery Managed Care protocols apply

GENERAL PRACTITIONER AND MEDICAL SPECIALIST

Reimbursement rate100% Sizwe rate for consultations and visits in-hospital

CHRONIC BENEFITSSubject to pre-authorisation.Medicines:subject to registration on the Chronic

Medicine Programme. PMBs subject to pre-authorisation, preferred providers and

treatment protocols)HIV/AIDS

(Members are encouraged to register with the HIV/AIDS Programme. This benefit includes relevant consultations, counselling, medication and the cost of blood tests for

monitoring purposes)


BenefitNo limits but subject to treatment protocols and PMB’s at a DSB H

ospital Care

PREVENTATIVE CAREWELLNESS SCREENING CONSULTATIONS


Benefit

Subject to a family limit of R2 030 for flu vaccine and pneumococcal vaccine. Mammograms: once in a 2 year cycle for females over 40 years Papsmear: once in a 2 year cycle for females over 21 years Prostate-Spe-cific Antigen (PSA): once per year for males over 40 years

BLOOD SUGAR, CHOLESTEROL, BLOOD PRESSURE, BMI AND HIV


Benefit R310

FEMALE CONTRACEPTIVES

Reimbursement rate No Benefit



MATERNITY

Reimbursement RateHospitalisation (public or private hospitals) delivery, post-natal services and midwifery

100% Sizwe Rate

BLOOD TRANSFUSIONS AND BLOOD REPLACEMENT PRODUCTS

Reimbursement rate

100% Sizwe rate, subject to PMBs and annual limit of R79 490 per family

PROSTHESIS

Reimbursement rate: pre-au-thorisation and managed care protocols apply

100% Sizwe rate, subject to an annual limit of R37 930 per family; maximum of 3 cardiac stents and 2 vascular stents per family per annum

ONCOLOGY


Benefit Overall limit of R320 000 per family



Specialised Radiology (MRI/CAT scan/ Anglogram) Pre-authorisation and managed care protocols

Limited to R25 270 per family

Interventional radiology

Payable from the hospital limit, subject to pre-authorisation and clinical protocols

PATHOLOGY


MENTAL HEALTH


Alcoholism, drug addiction, narcotism: subject to PMBs, pre-authorisation and minimum benefit package

3 days withdrawal treat-ment and up to 21 days rehabilitation at an appropriate facility

ORGAN TRANSPLANT AND RENAL DIALYSIS

(subject to pre-authorisation, minimum benefitpackage, treatment protocols and DSP)

Reimbursement rateSubject to PMB conditions and clinical protocols

Benefit Limited to R200 890 per family

REFRACTIVE SURGERY INCLUDING RADIAL KERATOTOMY

Benefit No Benefit

pg 10 Hospital Care

GOMOMO CAREProvides excellent value for money.

GPs, specialists and acute medicines are accessible through a selected

network provider.


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OUT OF HOSPITAL BENEFITSMATERNITY

(subject to care rules, formulary and clinical protocols of DSP)


Pregnancy scans 2 x 2D scans per pregnancy



Provider Network


Benefits

100% Sizwe rate, subject to managed care rules, formulary and clinical protocols of the DSP (Designated Service Provider)



Limits Only PMBs

Out of area visits4 visits per year per beneficiary, within the DSP network

SPECIALISTS


LimitsRequired benefits for the full year all visits subject to referreal from a GP

RADIOLOGY AND PATHOLOGY

Basic Radiology and pathology

Reimburse-ment rate

100% Sizwe rate: subject to managed care rules, formulary and clinical protocols

Specialised Radiology in and out: Benefit is R 7140 per family

Reimburse-ment rate

Combined In-hospital and Out of hospital



Benefits Only PMBs

MEDICATION

Acute Reimburse-ment rate

100% Sizwe rate: subject to care rules, formulary and clinical protocols of DSP

OTC Limits 300 per family

CHRONIC CONDITIONS (subject to pre-authorisation, registration on the chronic

medicine programme, formulary and clinical protocols of the DSP)


Benefits R7 870 per beneficiary

PMB 26

Non-PMB 0

PHYSIOTHERAPY(Include physiotherapists, speech therapists, clinical

psychologists, Podiatrist, equipment and external prosthesis)


DENTISTRY (Subject to Dental Management Programme - 0860 109 556)

Reimbursement rate

100% Sizwe rate: subject to managed care rules, formulary and clinical protocols

Limits

M: R2 770

M+1: R3 190

M+2: R3 470

M+3: R3 750

M+4: R4 010

M+5: R4 290

M+6: R4 710

OPTICAL BENEFITS (Subject to care rules, formulary and clinical protocols of DSP)


Cycle 2 years

Limit per family

M: R1 130 M+1: R1 300 M+2: R1 440 M+3: R2 070

CHRONIC BENEFITS(Subject to pre-authorisation.

Medicines: subject to registration on the Chronic Medicine Programme. PMBs subject to pre-authorisation, preferred providers and

treatment protocols.)Reimbursement rate 100% Sizwe rate

BenefitsR7 870 per beneficiary. Cover for 27 PMB chronic conditions

PMB At Cost

Non-PMB 100% Sizwe Rate

HIV/AIDS(Members are encouraged to register with the HIV/AIDS Programme. This benefit includes relevant consultations, counselling, medication and the cost of blood tests for



Benefits

Subject to PPDMP benefits include coun-seling, prescription medicine, pathology tests.’





BENEFITS


100% Sizwe rate

PRIVATE HOSPITALS AND NURSING HOMES

(Subject to treatment and case management protocols and PMBs. Pre-authorisation

required unless it is a medical emergency)



Clinical limitations

Advanced laparoscopic, reconstructive surgery, joint replacements, cardiac surgery including cardiac stents, spinal surgery, breast reconstructive surgery

Exclusions

Refractive surgery, breast reduction, breast augmentation, Keloids, Frail Care

DENTAL HOSPITALISATION(Subject to pre-authorisation, Dental Benefit

Management Programme and clinical protocols subject to R1 500 co-payment)

Reimbursement rate

Pre-authorisation is required, subject to managed care protocols and limited to PMBs level of care

General anaesthetic 100% Sizwe rate

Conscious sedation in roomsSubject to pre-authorisa-tion and limited to PMB level of care



GENERAL PRACTITIONER AND SPECIALIST


AUXILIARY SERVICES


Dietician, speech therapy, occu-pational therapy

Subject to clinical protocols and pre-au-thorisation

PHYSIOTHERAPY


MATERNITY(Hospitalisation [public or private hospitals] delivery,

post-natal services and midwifery)



Reimbursement rate 100% Sizwe rate: subject to PMBs

PROSTHESIS(Pre-authorisation and managed care

protocols apply)


Benefits R28 090 per beneficiary

ONCOLOGY




PATHOLOGY


MENTAL HEALTH(Subject to pre-authorisation and managed care rules)

Reimbursement rate

100% Sizwe rate


Psychiatry hospitalisation

Limited to 21 days per beneficiary per annumPsychiatrist consulta-tions and 6 in-hospital Clinical Psychologists subject to PMBs



Benefits

Restricted to PMBs, subject to pre-authori-sation, minimum benefit package, treatment protocols and DSP


Benefits No Benefit

OTHER SERVICES(Psychologists, Speech Therapists, Clinical Psychologists,

Podiologists, Equipment and External Prostheses)


Benefits R2 530 per family: subject to PMBs

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pg 12 Gomomo Care

PRIMARY CAREPrimary Care Option offers

good value for money with unlimited hospitalisation at any private hospital,

to meet the needs of any family.


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Provider Any


Benefits

M: R5 680M+1: R8 410M+2: R9 840M+3: R11 250M+4: R12 680M+5: R14 100M+6+: R15 520



Benefit

M: 4 M+1: 9 M+2: 12 M+3: 14 M+4: 15 M+5: 16 M+6+:17

SPECIALISTS (EXCLUDING PSYCHIATRISTS)


Benefits

All visits subject to referral from a GP Non-referral will result in M: 2M+1: 6M+2: 7M+3: 8M+4: 9M+5: 10M+6+: 11

ACUTE MEDICINES AND PHARMACY ADVISED THERAPY (PAT) - FALLS WITHIN DAY-TO-DAY BENEFIT WITH THE

FOLLOWING SUB-LIMITS


Structure Within day to day with, sub-limits:

Benefits

M: R1 770 M+1: R3 190 M+2: R3 550 M+3: R4 030 M+4: R4 140 M+5: R4 370 M+6+:R4 730

CHRONIC CONDITIONS


Benefits

Subject to PMB chronic conditions, pre-au-thoristion, registration on the chronic disease prgramme formolary and clinical protocols



Benefits Subject to managed care protocols

Specialised

Reimburse-ment Rate 100% Sizwe Rate

Benefits R18 680 per family for in and out of hospital

PHYSIOTHERAPY

Reimbursement rate Subject to day to day benefits

PATHOLOGY


Benefits Subject to day to day benefits

MENTAL HEALTH(Limited to Psychiatrist, Clinical, Counselling, Psychologist

excludes services covered under Auxillary Benefits)


Benefits R5 180 per family

DENTISTRY(Subject to Dental Management Programme - 0860 109 556)


Limit per beneficiary

2 general check ups a year per beneficiary once in six months Motivation may be requested for extensive restorative treatment plans (fillings)


Plastic dentures

Root Canal, Clinical protocols apply 1 set per jaw every 4 years

SPECIALISED DENTISTRY(Subject to pre-authorisation

and Dental Management Programme)

Benefits 100% Sizwe rate

Crowns and Bridges No Benefit

Orthodontics (Braces) No Benefit

Implants No Benefit

Partial Metal Frame Dentures No Benefit

Surgery Managed Care protocols apply

OPTICAL BENEFITS ACCESSED THROUGH (PPN)


Benefits No limit

Cycle 2 years

Limit per bb Limit per beneficiary

Frames R320

Single focus lenses R175 per lens

Bi-focal lenses R380 per lens

Multi-focal lenses R380 per lens

Contact lenses R1 200

AUXILIARY SERVICES (Speech Therapists, Podiatrists, Occupational Therapists,

Social Workers, Dieticians Audiologists, Chiropractors, Homeopathy, Educational Psychologists, Clinical

Technologist, Biokineticist and Registered Counsellors)

Reimbursement Rate 100% Sizwe rate

Benefits Risk benefit

Annual limit per family M: R1 010

Limits per family M+1+: R1 630

Chiropractor R1 000 per beneficiary

MATERNITY (Subject to registration on maternity

programme and 24 weeks of falling pregnant)


Ante-natal consultations 9 GP/Midwife visits; 2 Specialist visits




treatment protocols.)Reimbursement rate 100% Sizwe rate

Benefits Cover for 27 PMB chronic conditions

HIV/AIDS(Members are encouraged to register with the

HIV/AIDS Programme. This benefit includes rele-vant consultations, counselling, medication and the cost of blood tests for monitoring purposes)


Benefits

Subject to PPDMP benefits include counseling, prescription medicine, pathology tests.

IN-HOSPITAL BENEFITS(All hospital admissions must be authorised. A

co-payment of R1 500 will be applied if pre-authorisation was not obtained)



Primary C

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BENEFITS


100% Sizwe rate

PRIVATE HOSPITALS AND NURSING HOMES(subject to pre-authorisation and case management

protocols and PMB’s unless its a medical emergency)

Accommodation

A co-payment will apply to all unauthorised admissions unless it is an emergency. Unlimited at any private hospital


Clinical limitations and exclusions

Advanced laparoscopic, reconsructive surgery, joint replacements, cardiac surgery including cardiac stents, spinal surgery, breast reconstructive surgery

Exclusions

Refractive surgery, breast reduction, breast augmentation, Keloids, Frail Care

DENTAL HOSPITALISATION(Subject to pre-authorisation, Dental Benefit Management

Programme and clinical protocols subject to R1 500 co-payment on some options)


General anaestheticPre-authorisation is required, subject to managed care protocols

Laughing gas in dental rooms 100% Sizwe rate

Conscious sedation in roomsSubject to pre-authorisa-tion and managed care protocols



AUXILIARY SERVICES


AUXILIARY SERVICES


Benefits

Subject to pre–authori-sation and PMBs, limited to dieticians, speech therapy, occupational therapy and clinical technology

PHYSIOTHERAPY

Reimbursement ratePre-authorisation and managed care protocols apply

100% Sizwe rate

MATERNITY

Reimbursement rateHospitalisation (public or private hospitals) delivery, post-natal services and midwifery

100% Sizwe rate

BLOOD TRANSFUSIONS AND BLOODREPLACEMENT PRODUCTS

Reimbursement rate

100% of the cost of blood transfusions and blood replacement prod-ucts, limited to PMBs

PROSTHESIS

Reimbursement rate

100% Sizwe rate,Subject to pre-authorisa-tion, treatment protocols, DSPs and PMBsMaximum of 3 cardiac stents and 2 vascular stents per family per annumAnnual limit: R 25 600

ONCOLOGY


pg 14 Primary Care



Benefits Overall limit of R143 780 per family


Reimbursement rate 100% Sizwe rate:subject to clinical protocols

Specialised Radiology (MRI/CAT scan/ Anglogram) Pre-authorisa-tion and managed care protocols

Limited to R18 680 per family per annum



PATHOLOGY


MENTAL HEALTH




3 days withdrawal treat-ment and up to 21 days rehabilitation



Benefits Subject to PMBs at DSPs


Reimbursement rate No Benefit

PREVENTATIVE BENEFITS

WELLNESS SCREENING CONSULTATIONS


Consultation Benefits R1 000

Screening benefits

Subject to a family limitof R2 020 for flu vaccine and pneumococcal vaccine.

Mammograms: once in a 2 year cycle for females over 40 years

Papsmear: once in a 2year cycle for females over 21 years

Prostate-Specific Antigen (PSA): once per year for males over 40 years



Benefit R260

ORAL CONTRACEPTIVES


Benefits R2 620 per family per annum

OTHER BENEFITS: IN-HOSPITAL OR OUT-OF-HOSPITAL

AppliancesM: R1 010

M+1+:R1 630

Wheelchair R1 800 per family

Hearing aids R7 500 per family

Private nursing R4 540 per family


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AFFORDABLE CAREOffers generous comprehensive cover with unlimited hospitalisation in any

private hospital. This option is suitable for young and healthy families.

pg 16 Affordable Care

IN-HOSPITAL BENEFITS

AUXILIARY SERVICES(Dietician, Speech Therapy, Occupational Therapy)



Subject to pre–authori-sation and PMBs

PHYSIOTHERAPY(Pre-authorisation and managed care protocols apply)


MATERNITY(Hospitalisation [public or private hospitals]delivery, post-natal

services and midwifery)



Reimbursement rate 100% Sizwe rates; limited to PMBs

PROSTHESIS(Subject to pre-authorisation, treatment protocols and PMBs)

Reimbuirsement rate 100% Sizwe rate

Benefits

100% of costMaximum of 3 cardiac stents and 2 vascular stents per family per annumAnnual limit: R42 670

ONCOLOGY


Benefit R314 170 per family




Limited to R28 400 per family per annum, pre-authorisation and managed care protocols





Provider Any


Benefit

M: R9 840M+1: R14 100M+2: R16 230M+3: R17 660M+4: R19 790M+5: R21 930M+6+: R23 930

GENERAL PRACTITIONERS (CARE OPTION ONLY)


Benefits Limited number of visits

Chosen GP

M: 7M+1: 14M+2: 16M+3: 18M+4: 20M+5: 21M+6+: 22

SPECIALISTS


Benefits

Subject to referral by a GP, with the exception of: Follow-up visits, Emergencies, Gynaecologist and Paediatrician visits for babies up to the age of 12 months.

M: 4M+1: 8M+2: 9M+3: 10M+4: 11M+5: 12M+6+:13

ACUTE MEDICINES


Benefits

Within day to day

M: R3 420 M+1: R5 210 M+2: R6 160 M+3: R6 630 M+4: R7 580 M+5: R7 820 M+6+:R8 060



Benefits Subject to clinical protocols

Specialised Radiology: (MRI/CAT scan/Angio-gram) pre-au-thorisation and managed care protocols

Benefits

Subject to an overall combined in and out of hospital limit of R28 400 per family

MENTAL HEALTH

Reimbursement rate

100% Sizwe rateLimited to Psychiatrists, Clinical and Counselling Psychologists subject to R8 580 per family

Benefit Risk benefit

PHYSIOTHERAPY

Reimbursement Rate100% Sizwe RatePaid from the day to day limit

PATHOLOGY


OUT OF HOSPITAL BENEFITSDENTISTRY

(Subject to Dental Management Programme - 0860 109 556)


Benefits

2 general check ups a year per beneficiary Motivation may be re-quested for extensive re-storative treatment plans (fillings)

Plastic dentures

Clinical protocols apply

Root Canal: Managed Care Protocols apply

1 Set dentures, full or partial every 4 years



BenefitsBenefits: Subject to pre-authorised and managed care protocols

Crowns and bridges 1 Crown per family per year

Dentures

Partial frames per beneficiary in a 5 year period lmited to 1 beneficiary per annum

Orthodontic treatment

Pre-authorisation and clinical protocolsRestricted to beneficiary < 18 years, 35% co-pay

OPTICAL BENEFITS ACCESSED THROUGH PPN


Cycle 2 years

Benefits Limit per beneficiary

Frames R800





AUXILIARY SERVICES (Speech therapy; Podiatry; Occupational Therapy; Social Worker; Dietetics; Audiology, Homeopathy; Educational Psychologist; Biokineticist and Registered Counselor)

Reimbursement Rate 100% Sizwe rate

Benefits M: R 1 510 M+1+: R 2 640

MATERNITY (Subject to registration on the Sizwe Baby Programme within

24 weeks of falling pregnant)


Ante-natal consultations 9 GP/Midwife visits; 4 Specialist visits


IN-HOSPITAL BENEFITS(All hospital admissions must be authorised

R1500 co-payment will be applied if authorisa-tion was not obtained except in emergencies)

Annual LimitSubject to pre-authorisa-tion and managed care protocols

Provider Limits Preferred provider network

AMBULANCE SERVICES

100% cost as authorised by EUROP ASSIST SA (Telephone number: 0860 11 77 99)

PRIVATE HOSPITALS AND NURSING HOMES(Subject to treatment and case management protocolsand

PMBs. Pre-authorisation required unless it is a medical emergency. A co-payment will apply to all unauthorised

admissions unless it is an emergency.)



Clinical limitations and exclu-sions None

DENTAL HOSPITALISATION(Subject to pre-authorisation, Dental Benefit Management

Programme and clinical protocols subject to R1 500 co-payment)




Conscious sedation in roomsSubject to pre-authorisation and managed care protocols

GENERAL PRACTITIONER AND SPECIALIST


CHRONIC MEDICINES


PMB 26

Beneficiary R5 540 per beneficiary

Non PMB

M: R5 540 M+1: R11 090 M+2: R16 640 M+3: R22 190 M+4: R27 730M+5: R33 300M+6+:R38 850

HIV/AIDS(Members are encouraged to register with the HIV/AIDS Programme. This benefit includes relevant consultations, counselling, medication and the cost of blood tests for



Benefit Subject to treatment protocols and PMBs


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Benefits

Restricted to PMBs, subject to pre-authori-sation, minimum benefit package, treatment protocols and DSP


Reimbursement rate Limited to R6 310 per family

OVERALL ANNUAL LIMIT

R6310 per family per annum

PREVENTATIVE BENEFITSORAL CONTRACEPTIVES


Benefits R2 620 per family


Appliances M: R1 510M+1+1: R2 640

Wheelchair(Once every four years)

Limited to R3 150 per family

Hearing aids 12 000 Once in every 3 years

Private nursing R6 780

PREVENTATIVE CARE

Limits

Females:

Mammogram every 2 years for women above age 40 years:

Pap smear every 2 years for women above 21 years

Males (above 40 years): Prostate-Specific Antigen test

Screening & vaccines 2 020 per family

Wellness screening 260 per beneficiary

Wellness consults 1 470 per family

Contraceptives 2 620 per family

Chiropractors 1 300 per beneficiary

Affordable C

are

pg 18 Affordable Care

FULL BENEFIT CAREoffers comprehensive cover and

generous benefits to cover families and individuals who need access to

unlimited hospitalisation at any private hospital.


Sizwe H

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ospital Care

Gom

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arePrim

ary Care

Affordable C

areFull B

enefit Care


AUXILIARY SERVICES



Subject to pre–authori-sation and PMBs

PHYSIOTHERAPY

Reimbursement ratePre-authorisation and managed care protocols apply

100% Sizwe rate

MATERNITY

Reimbursement rateHospitalisation (public or private hospitals) delivery, post-natal services and midwifery

100% Sizwe rate


Benefits

100% of the cost of blood transfusions and blood replacement products, limited to PMBs

PROSTHESIS

Benefit limit: pre-authorisation and managed care protocols apply

100% of costSubject to pre-authorisa-tion, treatment protocols and PMBsMaximum of 3 cardiac stents and 2 vascular stents per family per annumAnnual limit: R56 330

ONCOLOGY


Benefit Overall limit of R377 010 per family


OPTION STRUCTURE Major Medical; Day to day: Risk

Provider Any


Limits

M: R16 230M+1: R21 930M+2: R24 650M+3: R27 490M+4: R30 350M+5: R33 190M+6+:R36 020

GENERAL PRACTITIONERS (ADDITIONAL GP VISITS PER FAMILY ON THE PRIMARY

CARE OPTION ONLY)


Benefits

Subject to availability in day to day limits

M: 12M+1: 20M+ 2: 25M+3: 29M+4: 30M+5: 31M+6+:32

SPECIALISTS (EXCLUDING PSYCHIATRISTS)


Benefits

M: 7 M+1: 12 M+2: 15 M+3: 16 M+4: 17 M+5: 19 M+6+:20

ACUTE MEDICINES AND PHARMACY ADVISED THERAPY (PAT) - FALLS WITHIN DAY-TO-DAY

BENEFIT WITH THE FOLLOWING SUB-LIMITS


Benefits subject to day to day limits

Limits

M: R4 620 M+1: R8 170 M+2: R9 480 M+3: R10 790M+4: R11 480M+5: R12 090M+6+:R12 680


Reimbursement rate 100% Sizwe rate on general radiology

Speacialists rates (MRI/CAT scan/Angiogram)

RateR37 360 per family in-hospital and out of hospital limit

Structure Combined In-hospital and Out of hospital

Limits R37 370 per family

CHRONIC CONDITIONS

Reimbursement rate

100% Sizwe rate subject to pre-authorisation preferred provider and treatment protocols

PMB 26 Chronic conditions

Non-PMB

M: R10 970M+1: R21 960M+2: R32 820M+3: R43 800M+4: R54 780M+5: R65 760M+6+:R76 750



Benefits Subject to R16 540 per family

PHYSIOTHERAPY


PATHOLOGY


Structure Risk benefit, within day to day limit

OUT OF HOSPITAL BENEFITSBASIC DENTISTRY

(Conservative Dentistry: Subject to Dental Management Programme - 0860 109 556)


Benefits

2 general check ups a year per bb Motivation may be re-quested for extensive re-storative treatment plans (fillings)

Plastic dentures

Clinical protocols apply

Root canal: subject to managed care protocols 1 per jaw every 4 years



Benefits

“3 crowns pfpa, 2 metal frames pfpa, 2 implants per bb/ 5 years limited to R3 690 per implant”

Orthodontic treatment

Pre-authorisation and clinical protocolsRestricted to bbs < 18 years

OPTICAL BENEFITS ACCESSED THROUGH A CONTRACTED SERVICE PROVIDER


Cycle 2 years

Frames R1 000





MENTAL HEALTH (Psychiatrists, Clinical and Counselling

Psychologists - only if related to mental health, excludes Educational Psychologists, Social Workers and

Registered Counsellors)


Benefits Subject to R16 540 per family

AUXILIARY SERVICES (Speech Therapy; Podiatry; Occupational Therapy; Social Worker; Dietetics; Audiology; Homeopathy; Educational Psychologist; Biokineticist and Registered Counselor)


Benefits M: R2 770M+1+: R4 660

MATERNITY (Subject to registration on the Sizwe Baby Programme within

24 weeks of falling pregnant)

Reimbursement Rate 100% Sizwe Rate




treatment protocols.)

Reimbursement rate

100% Sizwe rate subject to pre-authori-sation, preferred providers and Treatment Protocols

PMB At Cost

Non-PMB

M: R10 970M+1: R21 960M+2: R32 820M+3: R43 800M+4: R54 780M+5: R65 760M+6+:R76 750

Full Benefit C

areCHRONIC BENEFITS

(Subject to pre-authorisation.Medicines: subject to registration on the

Chronic Medicine Programme. PMBs subject to pre-authorisation, preferred providers and

treatment protocols.)HIV/AIDS MANAGEMENT PROGRAMME

(Members are encouraged to register with the HIV/AIDS Programme. This benefit includes relevant consultations, counselling, medication and the cost of blood tests for



BenefitNo limit, subject to treatment protocols and PMBs

IN-HOSPITAL BENEFITSAnnual Limits Unlimited

Provider Any

BENEFITSAMBULANCE SERVICESContracted EUROP ASSISTSA (Telephone number:0860 11 77 99

100% Sizwe rate

PRIVATE HOSPITALS AND NURSING HOMES(Subject to treatment and case management

protocols and PMBs. Pre-authorisation required unless it is a medical emergency)



Clinical limitations and exclu-sions None

DENTAL HOSPITALISATION(Subject to pre-authorisation, Dental Benefit

Management Programme and clinical protocols subject to R1 500 co-payment on some options)




Conscious sedation in roomsSubject to pre-authorisa-tion and managed care protocols



pg 20 Full Benefit Care



AppliancesM: R2 640 M+1+:R4 400

Private nursing Limit per family 9 080 per family

Chiropractors R2 000 per beneficiary

IN-HOSPITAL BENEFITSRADIOLOGY AND RADIOGRAPHY

General reimbursement rate 100% Sizwe rate


Limited to R37 360 per family per annumCombined in-hospital and out-of-hospital limit



PATHOLOGY


MENTAL HEALTH







Benefits Subject to PMBs



Benefits R12,120 per family per annum


WELLNESS CONSULTATIONS


Consultation benefits R1 470

Screening benefits

Subject to R2 875 per family for flu vaccine and pneumococcal vaccine.

Mammograms: once in a 2 year cycle for females over 40 years

Papsmear: once in a 2year cycle for females over 21 years

Prostate-Specific Antigen (PSA): once per year for males over 40 years



Benefit R260 per beneficiary

ORAL CONTRACEPTIVESReimbursement rate 100% Sizwe rate

Benefit R2,620 per family per annum


Sizwe H

istory2018 O

fferingsH

ospital Care

Gom

omo C

arePrim

ary Care

Affordable C

areFull B

enefit Care

Full Benefit C

are

2018 Contributions

HOSPITAL CARE

CHILD

% of total contribution paid to savings account

ADULT

PRINCIPAL

GOMOMO CARE

Contribution Income Band Contribution Income Band

R877R1 156R1 649R2 048

R0 - R7 147R7 148 - R8 337R8 338 - R10 719R10 720 +

R0 - R7 147R7 148 - R8 337R8 338 - R10 719R10 720 +

R0 - R7 147R7 148 - R8 337R8 338 - R10 719R10 720 +

R1 500 All

R867R1 156R1 592R1 672

R1 100 All

R365R419R458R489

R500 All

0%0%

2018 Contributions

PRIMARY CARE FULL BENEFIT CAREAFFORDABLE CARE

Contribution Income Band Contribution Income Band Contribution Income Band

R419R1 964R2 396

R4 336R5 032

R2 815R2 928R3 767

R0 - R562R563 - R9 292R9 293 +

< R32 499R32 500+

R0 - R15 955R15 956 - R32 499R32 500+

Traditional Traditional Traditional

R0 - R562R563 - R9 292R9 293 +

< R32 499R32 500+

R0 - R15 955R15 956 - R32 499R32 500+

R0 - R562R563 - R9 292R9 293 +

< R32 499R32 500+

R0 - R15 955R15 956 - R32 499R32 500+

R419R1 533R1 565

R3 940R4 574

R2 586R2 688R3 349

R419R494R494

R886R989

R649R680R752

0% 0%0%

pg 24 Full Benefit Care

CHRONIC MEDICATION PROGRAMME:Tel: 0860 103 455 | 011 353 0030 Fax: 011 353 0352/0076Email: [email protected] PRE-AUTHORISATION, HOSPITAL BENEFIT MANAGEMENT PROGRAMME:Tel: 0860 101 176

DENTAL BENEFIT MANAGEMENT:Tel: 0860 109 556 | Fax: 0866 770 336 Email: [email protected] PROGRAMME – HELPLINE FOR ASTHMA, CARDIOVASCULAR DISEASE, DIABETES AND MENTAL HEALTH:Tel: 0860 103 455 | Fax: 011 221 5238Email: [email protected]

IMPORTANT CONTACT DETAILS


Sizwe H

istory2018 O

fferingsH

ospital Care

Gom

omo C

arePrim

ary Care

Affordable C

areFull B

enefit Care

HIV/AIDS MANAGEMENT PROGRAMME:Tel: 0860 103 454 | Fax: 011 221 5235/56EUROP ASSISTANCE SA, MEDICAL EMERGENCIES, 24-HOUR AMBULANCE SERVICES AND MEDICAL ADVICE:Tel: 0860 117 799

SIZWE BABY PROGRAMME:Fax: 011 221 5218Email: [email protected]

TIP-OFFS ANONYMOUS FRAUD LINE:Tel: 0800 204 702 | Fax: 0800 007 788 Email: [email protected] MEDICATION PROGRAMME:Tel: 0860 103 455 | 011 353 0030 Fax: 011 353 0352/0076Email: [email protected]

IMPORTANT CONTACT DETAILS

[email protected] 100 871

Documents

Benefits Guide - · PDF fileSizwe Medical Fund - Benefits Guide pg 3 Sizwe History 2018 Offerings Hospital Care Gomomo Care Primary Care Affordable Care Full Benefit Care Sizwe History