Benefits Guide - 2018 - Sizwesizwe.co.za/ugd/BenefitsGuide2018.pdf · pg 10 Hospital Care kyg Ogfkecn wpf Dgpgvu wkfg 423: pg 11 Sizwe History 2018 Offerings Hospital Care Gomomo

Benefits Guide - 2018

Sizwe Medical Fund - Benefits Guide 2018 pg 3pg 2 Sizwe History

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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 South African Medical Discussion Group (SAMDG). The group discussed matters of interest in respect of black doctors and their patients, as the South African Medical Association (SAMA) was only open to white membership then.

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

The SAMDG met once a month on a Sunday afternoon, hosted by members at their homes. Spouses attended meetings and held their own meeting while members discussed the business of the day. In 1976, the SAMDG which was chaired by Dr. Mzamane of Katlehong in the Eastrand appointed its executive team.

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 Johannesburg General Hospital. He suggested that it would be good to register a medical aid scheme and a private hospital for blacks. He introduced the matter to some government officials who would make registration 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 South African society, assumed leadership of the group. In serving as the chairman of the group, he sold the idea to black doctors to take up shares and negotiated with white business to support the initiative.

In 1978, the Kwacha Group (Kwacha meaning ‘Day Break’ in Chewa - a Malawian language) was registered with 38 shareholders. Dr. Loots was the only white shareholder and also served on the board of directors. Sizwe Medical Fund was registered after shareholders had raised R3 million as security to meet medical claims. Lesedi Clinic opened its doors soon after Sizwe Medical Fund started operating. The Kwacha Group was later changed to Sechaba Group Holdings (Pty)Ltd.

The motivation for forming the Kwacha Group

• To provide medical aid cover for Blacks• To lead the black population in matters of healthcare• To enable black specialists to open private practice• To give black private patients and their doctors access to X-rays, other investigations and

expensive medications which were out of reach for virtually all who had no medical aid cover

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 other medical schemes to cater for various civil servants races.

The first members of Sizwe Medical Fund were drawn from the Barlow Rand Group, Iscor, PUTCO, steel companies and coal mining companies in Witbank and Middleburg as well as motor industry workers from Port Elizabeth and Uitenhage.

Forty years later, the initiative by our founding fathers continues to thrive.

Dr Tlakula

Sizwe Medical Fund - Benefits Guide 2018 pg 5pg 4 2018 Healthcare Offerings

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2018 Offerings

HOSPITAL CARE PRIMARY CARE FULL BENEFIT CAREGOMOMO CARE

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

This traditional option has generous day-to-day benefits which 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 a private hospital. Covers the 27 Chronic Disease List (CDL) conditions.

Our Full 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 at any private hospital.

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

This option is suitable for young and healthy families.

2018 HEALTHCARE OFFERINGS

pg 4 2018 Healthcare Offerings Sizwe Medical Fund - Benefits Guide 2018 pg5 - Subject to CMS approval

Sizwe Medical Fund - Benefits Guide 2018 pg 9pg 8 Hospital Care

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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

Auxillary Services: 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

HOSPITAL CAREOffers peace of mind

knowing that in the event of hospitalisation, extensive cover is available at a private hospital.

OUT OF HOSPITAL BENEFITS

Option Structure Major Medical; Day to day: PMB

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 annual limit Unlimited

Provider Network Contracted

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 -

accessed through DENIS - 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

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 CAREPREVENTATIVE TESTS


Consultation benefits No benefit

Screening 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

WELLNESS SCREENING TESTS(blood sugar, cholesterol, blood pressure, BMI and HIV)


Benefit R310

FEMALE CONTRACEPTIVES




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-authorisation 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

Sizwe Medical Fund - Benefits Guide 2018 pg 11pg 10 Hospital Care

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GOMOMO CAREProvides excellent value for money.

GPs, specialists and acute medicines are accessible through a selected

network provider.


Option Structure Major Medical; Day to day: Risk

Provider Network


Benefits

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



Limits

Subject to managed care rules, formulary and clinical protocols of the DSP

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

SPECIALISTS


Limits 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 (Advanced) Radiology in and out: Benefit is R 7140 per family

Reimburse-ment rate

Combined In and Out of Hospital

PSYCHIATRIC TREATMENT


Benefits Only PMBs

MEDICATION

Acute Reimburse-ment rate

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

Over the Counter (OTC) Limits R300 per family

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

disease management programme, formulary and clinical protocols of the DSP)


Benefits R7 870 per beneficiary

PMB 26

Non-PMB No benefit

DENTISTRY (Subject to Dental Management Programme - 0860 100 871)

(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 managed care rules, formulary and clinical

protocols of DSP)


FramesR490 per beneficiary subject to family limits below

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 Disease Management Programme. PMBs subject to pre-authorisation, preferred

providers and treatment protocols.)Reimbursement rate 100% Sizwe rate

Non PMB Benefits R7 870 per beneficiary.

PMBCover for 27 PMB chronic conditions (in-clusive of HIV/ AIDS)

HIV/AIDS(Members are encouraged to register with the HIV/AIDS Management Programme. This benefit includes relevant

consultations, counselling, medication and the cost of blood tests for monitoring purposes)


Benefits

Subject to Preferred Provider Disease Man-agement Programme (PPDMP) benefits include counseling, prescription medicine, pathology tests and relevant consultations




Provider Network Contracted network

BENEFITS


100% Sizwe rate

PRIVATE HOSPITALS AND NURSING HOMES

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

required unless it is a medical emergency)

Accommodation Unlimited at a private hospital


Clinical limitations

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

Exclusions

Refractive surgery including radial keratot-omy, breast reduction, breast augmentation, keloids, frail care

OTHER SERVICES(Physiotherapists, Speech Therapists, Clinical Psychologists,

Podiatrists, Equipment and External Prostheses)


Benefits R2 530 per family: subject to PMBs

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MATERNITY (ANTENATAL CARE)(subject to managed care rules, formulary and clinical proto-

cols of DSP)



2X2D scansBlood tests:2 Haemoglobin Measurement tests, 1 Blood Grouping test, 1 VDRL test for Syphilis and 1 HIV blood test

DENTAL HOSPITALISATION

Reimbursement rate Limited to PMB level of care

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(subject to pre-authorisation, treatment protocols and PMBs)


RADIOLOGY AND RADIOGRAPHY(Subject to Hospital Benefit Management Programme and Dis-ease Management Programme. Limited to PMB level of care)


PATHOLOGY(Subject to Hospital Benefit Management Programme and

Disease Management Programme)


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

Psychiatry hospitalisation

Limited to 21 days per beneficiary including psychiatrist consulta-tions and 6 in-hospital clinical psychologists subject to PMBs


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



Benefits Subject to Prescribed Minimum Benefit at DSP


Benefits No Benefit

IN HOSPITAL BENEFITS

Sizwe Medical Fund - Benefits Guide 2018 pg 13pg 12 Gomomo Care

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PRIMARY CAREPrimary Care Option offers

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

to meet the needs of any family.




Benefits

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



Visits

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

SPECIALISTS (EXCLUDING PSYCHIATRISTS)


Visits

All visits subject to refer-ral from a GP 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


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-authoris-tion, registration on the chronic disease man-agement programme, formulary and clinical protocols



Benefits Subject to managed care protocols

Specialised

Reimburse-ment rate

100% Sizwe rateSubject to pre-authorisa-tion and managed care protocols

Benefits R18 680 per family for in and out of hospital

PHYSIOTHERAPY

Reimbursement rate 100% Sizwe rate subject to day-to-day benefits

PATHOLOGY


Benefits Subject to managed care protocol

MENTAL HEALTH(Limited to Psychiatrists, Clinical and Counselling Psycholo-gists excludes services covered under Auxillary Benefits)


Benefits R5 180 per family

OUT OF HOSPITAL BENEFITSDENTISTRY

(Subject to Dental Management Programme - accessed through DENIS - 0860 109 556)



Limit per beneficiary

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

Root canal treatment Subject to managed care protocols

Plastic dentures

1 set of plastic dentures, full or partial (an upper and a lower) per benefi-ciary in a 4-year period

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 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, Clinical Technologist, Biokineticist and

Registered Counsellors)


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 within 24 weeks of falling pregnant)


Ante-natal consultations

9 GP/ Midwife/ Special-ists visitsAdditional 2 Specialist visits

Pregnancy scans 2 x 2D scans per pregnancy


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

providers and treatment protocols.)


Benefits Cover for 27 PMB chronic conditions

Primary C

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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)

BENEFITS


Provider Contracted network


100% Sizwe rate

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

protocols and PMB unless it is a medical emergency)

Accommodation

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


Clinical limitations and exclusions

Advanced laparoscopic, reconstruction 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)


General anaesthetic(Children under the age of 5 for extensive dental treatment)

Pre-authorisation is required, subject to managed care protocols

Laughing gas in rooms 100% Sizwe rate

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



AUXILIARY SERVICES


Benefits

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

PHYSIOTHERAPY

Reimbursement rate100% Sizwe rateSubject to pre-authorisa-tion and managed care protocols apply





HIV/AIDS(Members are encouraged to register with the HIV/AIDS Manage-

ment Programme. This benefit includes relevant consultations, counselling, medication and the cost of blood tests for monitoring

purposes)


Benefits

Subject to Preferred Provider Disease Management Programme(PPDMP)benefits include counseling, prescription medicine, pathology tests and relevant consultations

Sizwe Medical Fund - Benefits Guide 2018 pg 15pg 14 Primary Care

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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.

PREVENTATIVE BENEFITSPREVENTATIVE TESTS


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 per beneficiary

ORAL CONTRACEPTIVES


Benefits R2 620 per family per annum

OTHER BENEFITS

Appliances M: R1 010M+1+:R1 630

Non-motorised wheelchair R1 880 per family Once in every 4 years

Hearing aidsR7 500 per familyOne unit per beneficiary every 4 years

Private nurseR4 540 per familySubject to pre-authori-sation

IN HOSPITAL BENEFITSMATERNITY

(Subject to registration on the Sizwe Baby Programme within 24 weeks of falling pregnant)

Reimbursement rate

100% Sizwe rate

Hospitilisation(public or private hospital), deliv-ery, post natal services and midwifery

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 for both surgical and non-surgical

ONCOLOGY


Benefits Overall limit of R143 780 per family

RADIOLOGY AND RADIOGRAPHY(Subject to clinical protocols)


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

Limited to R18 680 per family



PATHOLOGY(Subject to the Hospital Benefit Management and Disease

Management programmes)


MENTAL HEALTH


Limited to 21 days per beneficiary Psychiatrist consultations and 6 in-hospital Clinical Psychologists subject to PMBs





Benefits Subject to PMBs at DSPs


Reimbursement rate No Benefit

Sizwe Medical Fund - Benefits Guide 2018 pg 17pg 16 Affordable Care

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IN-HOSPITAL BENEFITSPROSTHESIS

(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



IN-HOSPITAL BENEFITSAUXILIARY SERVICES

(Dietician, speech therapy, occupational therapy)


Benefits Subject to pre–authori-sation and PMBs

PHYSIOTHERAPY(Pre-authorisation and managed care protocols apply)


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

tal services and midwifery)



Reimbursement rate 100% Sizwe rates; limited to PMBs



Provider Any


Benefit

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



Benefits Limited number of visits

Visits

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

SPECIALISTS


Visits

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






Benefits

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

Root Canal treatment Subject to managed care protocols

Plastic dentures




BenefitsSubject to pre-authorisa-tion and managed care protocols

Crowns and bridges 1 Crown per family per year

Dentures metal

2 partial frames (an upper and a lower) per beneficiary in a 5 year period, limited to 1 family member per annum

Orthodontic treatment

Pre-authorisation and clinical protocolsRestricted to beneficiary 9 years and younger than 18 years of age, 35% co-payment)



Cycle 2 years

Benefits Limit per beneficiary

Frames R800





AUXILIARY SERVICES (Speech therapy, Podiatry, Occupational Therapy, Social

Worker, Dietetics, Audiology, Homeopathy, Biokineticist and Registered Counselor)


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

MATERNITY (ANTENATAL)(Subject to registration on the Sizwe Baby Programme within

24 weeks of falling pregnant)


Ante-natal consultations

9 GP, Midwife or specialists visits

Additional 2 Obstetrician /specialist visits



Infertility No benefit

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 Network Any

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 protocols and

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


PREVENTATIVE BENEFITSReimbursement rate 100% Sizwe rate

Consultation benefits R1 470 per family

Screening limits

Subject to R2 020 per family for flu vaccine and pneumococcal vaccine

Mammogram every 2 years for women above age 40 years

Pap smear every 2 years for women above 21 years

Prostate-Specific Anti-gen (PSA) once per year for males over 40 years

ORAL CONTRACEPTIVES


Benefits

R2 620 per family per annum

Subject to managed care protocols and formulary

OTHER BENEFITS

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

Non-motorised wheelchairLimited to R3 150 per familyOnce in every 4 years

Hearing aidsR12 000 per familyOne unit per beneficiary every 4 years

Private nurse R6 780

Chiropractors R1 300 per beneficiary

Affordable C

areOUT OF HOSPITAL BENEFITS

CHRONIC MEDICINES


PMB conditions 27

Limit 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 Management Programme. This benefit includes relevant



Benefit Subject to treatment protocols and PMBs

IN-HOSPITAL BENEFITS


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



PATHOLOGY


MENTAL HEALTH


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


Reimbursement rate Limited to R6 310 per family

Sizwe Medical Fund - Benefits Guide 2018 pg 19pg 18 Affordable Care

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IN-HOSPITAL BENEFITSAUXILIARY SERVICES


Dietician, speech therapy, occu-pational therapy

Subject to PMBs, clinical protocol and pre–au-thorisation

PHYSIOTHERAPY

Reimbursement rate100% Sizwe ratePre-authorisation and managed care protocols apply

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

tal services and midwifery)




BenefitsSubject to an annual limit R 79 490 per familySubject to PMBs

FULL BENEFIT CAREoffers comprehensive cover and

generous benefits to cover families and individuals who need access to

unlimited hospitalisation at any private hospital.


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



Visits

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)


Visits

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



Specialised Radiology (MRI/CAT scan/Angio-gram)

BenefitsR37 360 per family in-hospital and out of hospital limit

CHRONIC MEDICINES

Reimbursement rate

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

PMB conditions 27

Benefit limit

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

PHYSIOTHERAPY


PATHOLOGY


Benefits Subject to day-to-day limit




Reimbursement rate100% Sizwe rateSubject to day-to-day benefits

Benefits

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

Root canal treatment Subject to managed care protocols

Plastic dentures




Benefits

2 Partial metal frames (upper and lower) per beneficiary in a 5-year period, limited to 2 family members per annum

3 Crowns per family per year

Implants limited to R3 690 per implant

Orthodontic treatment

Pre-authorisation required and benefit limited to age 9 and younger than 18 years of age.20% co-payment will apply if authorisation is obtained after the treatment.


Reimbursement rate 100% Sizwe rate per beneficiary

Cycle 2 years

Frames R1 000





MENTAL HEALTH (Limited to Psychiatrists, Clinical and Counseling Psycholo-gists. Benefit excludes services covered under the auxiliary

benefit)


Benefits Subject to R16 540 per family

AUXILIARY SERVICES (Speech Therapy, Podiatry, Occupational Therapy, Social

Worker, Dietetics, Audiology, Homeopathy, Biokineticist and Registered Counselor)


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

MATERNITY (ANTENATAL)(Subject to registration on the Sizwe Baby Programme within

24 weeks of falling pregnant)


Ante-natal consultations9 GP, Midwife or Specialist visits6 Specialist visits



Infertility Subject to PMB regulation

Full Care

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







Reimbursement rate

100% Sizwe rate subject to pre-authori-sation, preferred providers and treatment protocols

PMB conditions 27

Non-PMB(Subject to a maximum of R10 970 per beneficiary)

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

HIV/AIDS MANAGEMENT PROGRAMME(Members are encouraged to register with the HIV/AIDS Management Programme. This benefit includes relevant



BenefitNo limit, subject to treatment protocols and PMBs

Sizwe Medical Fund - Benefits Guide 2018 pg 21pg 20 Full Benefit Care

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IN-HOSPITAL BENEFITSRADIOLOGY AND RADIOGRAPHY



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



PATHOLOGY


MENTAL HEALTH


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





Benefits Subject to PMBs



Benefits R12 120 per family per annum

PREVENTATIVE BENEFITSPREVENTATIVE TESTS


Consultation benefits R1 470 per family

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

Full Benefit C

areIN-HOSPITAL BENEFITS

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

PREVENTATIVE BENEFITSOTHER BENEFITS

Appliances M: R2 640 M+1+: R4 400

Non-motorised wheelchairLimited to R4 390 per familyOnce in every 4 years

Hearing AidsR18 000 per familyOne unit per beneficiary every 4 years

Private nurse R9 080 per family

Chiropractors R2 000 per beneficiary

2018 Contributions

HOSPITAL CARE

CHILD

% of total contribution paid to savings account

ADULT

PRINCIPAL

PRIMARY CARE FULL BENEFIT CAREGOMOMO CARE AFFORDABLE CARE

Contribution Income Band Contribution Income Band Contribution Income Band Contribution Income Band Contribution Income Band

R837R1 167R1 665R2 068

R419R1 964R2 396

R4 336R5 032

R2 815R2 928R3 767

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

R0 - R562R563 - R9 292R9 293 +

R0 - R 25 999R26 000+

R0 - R15 955R15 956 - R25 999R26 000+

Traditional Traditional Traditional

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

R0 - R562R563 - R9 292R9 293 +

R0 - R 25 999R26 000+

R0 - R15 955R15 956 - R25 999R26 000+

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

R0 - R562R563 - R9 292R9 293 +

R0 - R 25 999R26 000+

R0 - R15 955R15 956 - R25 999R26 000+

R1 500 All

R827R1 167R1 608R1 688

R419R1 533R1 565

R3 940R4 574

R2 586R2 688R3 349

R1 100 All

R348R423R463R494

R419R494R494

R886R989

R649R680R752

R500 All

0% 0% 0%0%0%

Sizwe Medical Fund - Benefits Guide 2018 pg 25pg 24 Full Benefit Care

Sizwe H

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Affordable C

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enefit Care

EUROP 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]

CHRONIC MEDICATION PROGRAMME:Tel: 0860 103 455 | 011 353 0030 Fax: 011 353 0352/0076Email: [email protected]

CHRONIC MEDICATION PROGRAMME:Tel: 0860 103 455 | 011 353 0030 Fax: 011 353 0352/0076Email: [email protected]

HOSPITAL PRE-AUTHORISATION, HOSPITAL BENEFIT MANAGEMENT PROGRAMME:Tel: 0860 101 176

DENTAL BENEFIT MANAGEMENT:Tel: 0860 109 556 | Fax: 0866 770 336 Email: [email protected]

WELLNESS PROGRAMME – HELPLINE FOR ASTHMA, CARDIOVASCULAR DISEASE, DIABETES AND MENTAL HEALTH:Tel: 0860 103 455 | Fax: 011 221 5238Email: [email protected]

HIV/AIDS MANAGEMENT PROGRAMME:Tel: 0860 103 454 | Fax: 011 221 5235/56

IMPORTANT CONTACT DETAILS

[email protected] 100 871

Documents

Benefits Guide - 2018 - Sizwesizwe.co.za/ugd/BenefitsGuide2018.pdf · pg 10 Hospital Care kyg Ogfkecn wpf Dgpgvu wkfg 423: pg 11 Sizwe History 2018 Offerings Hospital Care Gomomo