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book Glossary
Agreed Rate The agreed rate is the negotiated tariff fee payable to any Designated Service Provider including those listed on the Network. GRP The generic reference price - the Fund basis its medicine benefits on the cost of generic medicines instead of brand name medicines. Momentum Health Solutions Momentum Health Solutions is contracted to the Scheme for all managed healthcare services and the management of the Scheme's provider network. Scheme rate The Scheme rate is the tariff set by the Fund for reimbursement of claims, in the absence of any other agreed or contracted tariff with any service provider. SEP The single exit price is the legislated price of medicine. UPFS The uniform patient fee schedule is the fee schedule applied by the public sector. PMB CDL Prescribed Minimum Benefits(PMB) Chronic Disease List (CDL): PMBs are benefits that medical scheme must offer in terms of the Medical Schemes Act 131 of 1998.
Standard Option
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PRIVATE HOSPITAL OR STATE FACILITY
A co-payment of R375 will apply to all hospital admissions(including emergencies), except for cases where a R500 co-payment is indicated for specific procedure performed in a private facility
No co-payment will apply to an admission or procedure in a state facilityContracted private hospitals and State facilities within the Western Cape
Subject to annual in-hospital limit of R191 900 per beneficiary per year
All admissions and procedures in hospital are subject to:
authorisation 48 hours before the admission or, in the event of an emergency, within 24 hours of the admission or on the next working day
clinical protocols
100%
of Agreed rate
Non-contracted private hospitals and State facilities outside the Western Cape
Subject to annual in-hospital limit of R191 900 per beneficiary per year
All admissions and procedures in hospital are subject to:
authorisation 48 hours before the admission or, in the event of an emergency, within 24 hours of the admission or on the next working day
clinical protocols
100%
of Scheme rate
General practitioner
Please note a co-payment equal to the difference between the Scheme rate and GP rate may apply
Subject to annual in-hospital limit of R191 900 per beneficiary per year
100%
of Scheme rate
Specialist (non-network provider)
Please note that a co-payment equal to the difference between the scheme rate and specialist rate may apply if non-network specialist is used
Subject to annual in-hospital limit of R191 900 per beneficiary per year
100%
of Scheme rate
Specialist (network provider)
Subject to annual in-hospital limit of R191 900 per beneficiary per year
100%
of Agreed rate
Maternity
You must register your pregnancy by calling the pre-authorisation department. This will ensure that your maternity claims are paid correctly. Any other costs incurred at the time of the visit will be paid from your benefits, as specified in the rules of the Fund.
Once the maternity treatment plan benefit limits have been reached, tests will be paid from the applicable benefit limit. Subject to annual in-hospital limit of R191 900 per beneficiary per year
MATERNITY TREATMENT PLAN
Pathology out-of-hospital: The following benefits will be paid from the overall annual in-hosptial benefits as part of the maternity treatment plan: Test Per Year Tariff Code Full blood count 1 3755 Blood test: Blood group 1 3764 Blood test: Rhesus antigen 1 3765 Urine culture 1 3893 HIV Elisa or other screening test 1 3932 Rubella antibody 1 3948 Venereal Disease Research Laboratory (VDRL) test 1 3949 Glucose strip test 1 4050 Urine analysis dipstick) 13 4188 HIV antibody rapid test 1 4614 Hepatitis B screening 1 3942 Haemoglobin estimation 1 3762 Antenatal visits: Paid from overall annual in-hospital benefit Maximum per pregnancy (for high risk patients an additional 4 visits will be allowed, subject to approval and clinical motivation) 5 Ultrasound scans At 12 and 24 weeks 2 3615
3617
43250Antenatal vitamins during pregnancy and up to one month after delivery: Limited to R140 per month, including VAT and dispensing fee Case managed up to a maximum of 3 days for normal delivery and 4 days for caesarean
Gynaecologist
vaginal delivery (tariff code 2614)
caesarean delivery (tariff code 2615) Subject to annual in-hospital limit of R191 900 per beneficiary per year
Up to
200%
of Scheme rate
Intensive care unit
Subject to annual in-hospital limit of R191 900 per beneficiary per year
100%
of Agreed rate
Radiology
Subject to annual in-hospital limit of R191 900 per beneficiary per year
100%
of Scheme rate
Pathology
Subject to annual in-hospital limit of R191 900 per beneficiary per year
100%
of Scheme rate
Allied health services, i.e. physiotherapist, occupational therapist, dietician, social worker, clinical psychologist, speech therapist, etc.
Specialist motivation is required and authorisation must be obtained prior to treatment
Subject to annual in-hospital limit of R191 900 per beneficiary per year
Limited to R3 600 per admission for a qualifying diagnoses
No benefit for Dietician and Physiotherapy allowed in the case of a confinement
100%
of Scheme rate
Substance and alcohol abuse
Authorisation must be obtained prior to admission
Designated service provider must be used
Subject to annual in-hospital limit of R191 900 per beneficiary per year
No co-payment per admission will apply in private and state facilities
Subject to 1 admission per beneficiary per year and limited to 21 days' hospital-based treatment and 3 days' detoxification
Subsequent admissions to State facility only; uniform patient fee schedule (UPFS) rates applicablePsychiatric care
Authorisation must be obtained prior to admission
Designated service provider must be used
Subject to annual in-hospital limit of R191 900 per beneficiary per year
A co-payment of R375 per admission will apply in private facilities
Subject to 1 admission per beneficiary per year and limited to 21 days' hospital-based treatment our up to 15 outpatient consultations
Subsequent admissions to State facility only; uniform patient fee schedule (UPFS) rates applicableMRI and CT scans
Authorisation must be obtained prior to treatment
Limited to R10 100 per family per year
Subject to annual in-hospital limit of R191 900 per beneficiary per year
Out-of-hospital: A co-payment of R250 per event will apply in private facilities
In-hospital: No co-payment will apply in private and state facilities
100%
of Scheme rate
Internal prostheses and joint replacements
Defined as appliances placed internally in the body during an operation as well as the replacement of artificial eyes and limbs
Dental implants of any nature are not included in the definition of internal prostheses Limited to R60 400 per beneficiary per year
Subject to annual in-hospital limit of R191 900 per beneficiary per year
Maxillofacial and oral surgery
Trauma cases only as a result of an emergency or accident
No benefit for selective admission for specialised or advanced dentistry
Subject to annual in-hospital limit of R191 900 per beneficiary per year
100%
of Scheme rate
To-take-out medicine
Upon discharge from hospital
Subject to annual in-hospital limit of R191 900 per beneficiary per year
Maximum of five days' supply
Radiotherapy and chemotherapy (for instance cancer treatment)
Authorisation must be obtained prior to treatment
Subject to annual in-hospital limit of R191 900 per beneficiary per year
Treatment at State facility only; uniform patient fee schedule (UPFS) rates applicable
Transplants
Authorisation must be obtained prior to treatment
Subject to annual in-hospital limit of R191 900 per beneficiary per year
Treatment at State facility only; uniform patient fee schedule (UPFS) rates applicable
Cardiothoracic interventions and surgeries (including angiograms)
Authorisation must be obtained prior to treatment
Subject to annual in-hospital limit of R191 900 per beneficiary per year
Treatment at State facility only; uniform patient fee schedule (UPFS) rates applicable
Neurosurgery
Authorisation must be obtained prior to treatment
Subject to annual in-hospital limit of R191 900 per beneficiary per year
Treatment at State facility only; uniform patient fee schedule (UPFS) rates applicable
Renal dialysis
Authorisation must be obtained prior to treatment
Subject to annual in-hospital limit of R191 900 per beneficiary per year
Treatment at State facility only; uniform patient fee schedule (UPFS) rates applicable
Refractive surgery (Lasik)
Not a benefit of the Fund
Care in lieu of hospitalisation
Authorisation must be obtained prior to treatment
Benefits includes:
Protocol-based initiatives to prevent avoidable hospitalisation
May include home nursing
May include rehabilitation or terminal care Subject to annual in-hospital limit of R191 900 per beneficiary per year
Subject to managed care protocols
Frail care nursing services
Not a benefit of the Fund
Specialised procedures i.e. scopes
Includes disposable costs
Members will be liable for any costs in excess of the specified benefits
Limited to R36 000 per family per year
Also subject to annual in-hospital limit of R191 900 per beneficiary per yearA co-payment of a R500 will apply for the following procedures in a private facility: Gastroscopy
Colonoscopy
Laparoscopy
Sigmoidoscopy
Cystoscopy
Cataract surgeryNo co-payment will apply if performed in the doctor's rooms, provincial or State facility.
Benefits for diagnostic, laparoscopic and endoscopic surgery at a designated facility
Circumcisions
a) Performed out of hospital
Authorisation must be obtained prior to treatment
Subject to annual in-hospital limit of R191 900
No co-payment will apply if the procedure is performed in the doctor's rooms or a state facilitiy
b) Performed in hospital
A co-payment of a R500 will apply in a private facility
Authorisation must be obtained prior to treatment
Subject to annual in-hospital limit of R191 900
No co-payment will apply if the procedure is performed in the doctor's rooms or a state facilitiy
Trauma units
Benefit limited to stabilisation of patient only and thereafter transferral to designated service provider
Subject to authorisation and case management
Subject to annual in-hospital limit of R191 900 per beneficiary per year
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HIV/AIDS
Hospital pre-authorisation is required
Designated service provider must be usedThis benefit is subject to enrolment on the HIV/AIDS Programme
Subject to annual in-hospital limit of R191 900 per beneficiary per year
100%
of Agreed rate
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PREVENTATIVE CARE BENEFIT
Consultations and/or any other costs incurred at the time of the visit will be paid from your benefits as specified in the rules of the Fund.
Out-of-hospital Preventative Care Procedures/Services
100% of Scheme rate
Paid from overall annual in-hospital benefit limit Flu vaccine
Limited to 1 per beneficiary per year Pap smear
Limited to 1 per female beneficiary per yearAt Dis-Chem or Clicks pharmacies or tariff codes 4566/4559
Health risk assessment (HRA) - Body mass index, blood pressure measurement, cholesterol screening (finger-prick test) and blood sugar screening (finger-prick test)
Limited to 1 screening per adult beneficiary per yearAt Dis-Chem or Clicks pharmacies
Should your HRA be performed in the doctor's room, the consultation fee will be paid from your available GP visits benefit Cholesterol test
Limited to 1 per beneficiary per yearOnly 1 of the following tariff codes will be allowed: 4025, 4026, 4027, 4028 or 4170
Mammogram
Limited to 1 per female beneficiary every 2 years or as clinically indicatedSubject to the following criteria:
Females over 40 years
Motivation and pre-authorisation requiredOne of the following tariff codes will be allowed: 3605 or 34100/01/10/20/30/50
HIV test
Limited to 1 per beneficiary per yearTariff code 3932
Colorectal screening
Limited to 1 per beneficiary per yearSubject to the following criteria:
Beneficiaries 50 years and older Tariff code 4351 or 4352 Prostate-specific antigen (PSA) test
Limited to 1 per male beneficiary per yearTariff code 4519 or 4524
Male circumcision (in GP’s rooms)
Limited to 1 per male beneficiary per yearTariff code 2133, 2137 or 2139
Pneumococcal vaccine (Pneumovax only)
Limited to 1 per beneficiary per yearSubject to the following criteria:
Beneficiaries over 65 yearsHigh risk patients only: Patients diagnosed with cancer, asthma, chronic obstructive pulmonary disease, cardiac failure or HIV
Children:
Human papillomavirus (HPV)
Maximum of 3 per beneficiary, depending on vaccination manufacturerMale and female beneficiaries between the ages of 9 and 18
Child and infant vaccinations:
Subject to the Baby and child vaccine formularyState protocols apply