Hospitalisation and Related Benefits

The following benefit enhancements were approved by the Board of Trustees and will be implemented with effect from 1 January 2019.
  • Hospitalisation Facilities
    Private Hospitals, State (Public) Hospitals, Registered Unattached Operating Theatres, Day Clinics
    Accommodation

    General Ward, High Care Ward and Intensive Care Unit

    Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year

    Subject to pre-authorisation by the Society's designated agent or hospital DSP

    Subject to the overall annual limit of R2 100 000 (2018) or R2 200 000 (2019) per family per annum, this includes in-hospital consultations.

    100% of agreed tariff at DSP

    or

    90% of agreed tariff at other providers
    Theatre fees

    Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year

    Subject to pre-authorisation by the Society's designated agent or hospital DSP

    Subject to the overall annual limit of R2 100 000 (2018) or R2 200 000 (2019) per family per annum

    100% of agreed tariff at DSP

    or

    90% of agreed tariff at other providers
    Medicines, materials and hospital equipment

    Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year

    Subject to pre-authorisation by the Society's designated agent or hospital DSP

    Subject to the overall annual limit of R2 100 000 (2018) or R2 200 000 (2019) per family per annum

    100% of cost
    (to-takeout [TTO] medication limited to seven days' supply at DSP

    or

    90% of agreed tariff at other providers
    Visits by medical practitioners

    Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year

    Subject to pre-authorisation by the Society's designated agent or hospital DSP

    Subject to the overall annual limit of R2 100 000 (2018) or R2 200 000 (2019) per family per annum

    100% of cost, up to a maximum of 100% of the Society rate

    If a network provider is used, 150% of the Society rate
    Nursing services and all other non-psychiatric, inhospital services

    Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year

    Subject to pre-authorisation by the Society's designated agent or hospital DSP

    Subject to the overall annual limit of R2 100 000 (2018) or R2 200 000 (2019) per family per annum

    100% of agreed tariff at DSP

    or

    90% of agreed tariff at other providers
    Confinement and midwives

    Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year

    Subject to preauthorisation by the Society's designated agent or hospital DSP

    Subject to the overall annual limit of R2 100 000 (2018) or R2 200 000 (2019) per family per annum

    100% of agreed tariff at DSP

    or

    90% of agreed tariff at other providers
  • Surgical Procedures
    All in-hospital services, namely operations, procedures and consultations
    All in-hospital services, namely operations, procedures and consultations

    Subject to preauthorisation by the Society's designated agent or hospital DSP

    Excludes dental implants, unless indicated as an essential part of another pre-authorised dental procedure.

    Includes elective orthognatic surgery and maxillofacial surgery

    Subject to the overall annual limit of R2 100 000 (2018) or R2 200 000 (2019) per family per annum

    100% of cost, up to a maximum of 100% of the Society rate. Network Providers: PMB and Non-PMB 150% of MSR Non-Network Providers: PMB 100% of cost Non-PMB 100% of MSR for 2019
  • In-Hospital Psychiatric Treatment
    Includes treatment for substance abuse
    Accommodation

    Benefit is not adjusted in proportion to the number of months of membership if member joins during benefit year.

    Includes treatment on a day-patient basis instead of hospitalisation.

    The benefits in respect of PMBs will be limited, as per Annexure A of the Regulations of the Medical Schemes Act

    Subject to pre-authorisation

    Limited to 21 days per beneficiary per annum

    Where the treatment is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the service being rendered.

    100% of cost, up to a maximum of 100% of Society rate
    Medicines, materials and hospital equipment

    Benefit is not adjusted in proportion to the number of months of membership if member joins during benefit year.

    Includes treatment on a day-patient basis instead of hospitalisation.

    The benefits in respect of PMBs will be limited, as per Annexure A of the Regulations of the Medical Schemes Act

    Subject to pre-authorisation

    Limited to 21 days per beneficiary per annum

    Where the treatment is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the service being rendered.

    100% of cost (to-take-out [TTO] medication limited to seven days' supply)
    Consultations by medical practitioners

    Benefit is not adjusted in proportion to the number of months of membership if member joins during benefit year.

    Includes treatment on a day-patient basis instead of hospitalisation.

    The benefits in respect of PMBs will be limited, as per Annexure A of the Regulations of the Medical Schemes Act

    Subject to pre-authorisation

    Limited to 21 days per beneficiary per annum

    Where the treatment is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the service being rendered.

    100% of Society rate
  • In-hospital Physiotherapy and Auxiliary services
    including Audiology and Occupational and Speech therapy

    Subject to pre-authorisation

    Subject to overall annual limit of R2 100 000 (2018) or R2 200 000 (2019) per family per annum

    100% of Society rate for non-PMB.

    100% of cost for PMBs.
  • Sub-Acute facilities
    Alternatives to Hospitalisation, excludes frail care facilities
    Step-down nursing facilities

    Subject to pre-authorisation by the Society's designated agent

    Subject to overall annual limit of R2 100 000 (2018) or R2 200 000 (2019) per family per annum

    100% of Society rate or agreed tariff at DSP, whichever is applicable
    Private nursing (instead of hospitalisation)

    Subject to pre-authorisation by the Society's designated agent

    Limited to R26 400 (2018) or R27 850 (2019) per family per annum

    Subject to overall annual limit of R2 100 000 (2018) or R2 200 000 (2019) per family per annum

    100% of Society rate
    Hospice

    Subject to pre-authorisation by the Society's designated agent

    Subject to overall annual limit of R2 100 000 (2018) or R2 200 000 (2019) per family per annum

    100% of cost for PMBs
    Post hospitalisation benefit (instead of hospitalisation)

    Post-hospitalisation and cardiac rehabilitation benefit must be in accordance with an authorised treatment plan

    Subject to pre-authorisation by the Society's designated agent

    Subject to overall annual limit of R2 100 000 (2018) or R2 200 000 (2019) per family per annum

    90 days per diagnosis

    100% of Society rate
    Hospital prevention

    Subject to pre-authorisation by the Society's designated agent

    The Society's designated agent will liaise with the case manager of the hospital and the treating doctor to assess the appropriateness of transferring certain beneficiaries to stepdown facilities

    The Society's designated agent will arrange for and manage the appropriate alternatives to hospitalisation upon discharge from hospital, such as to join the cardiac rehabilitation programme at an accredited provider, to visit rehabilitation or sub-acute facilities or receive home nursing in accordance with a clinical motivation from doctors and case managers.

    Subject to overall annual limit of R2 100 000 (2018) or R2 200 000 (2019) per family per annum. Once the sub-limits are reached, only the diagnosis, treatment and care costs for PMB conditions will be paid in full

    100% of Society rate

    or

    100% of cost where no Society rate exists
  • Rehabilitation
    After Hospital discharge
    Following a hospital event

    Subject to preauthorisation

    Includes extended physiotherapy and occupational and speech therapy and biokinetics of a rehabilitative nature that is preceded by hospitalisation.

    Subject to overall annual limit of R2 100 000 (2018) or R2 200 000 (2019) per family per annum

    100% of Society rate
    Maintenance therapy

    Subject to preauthorisation

    Includes extended physiotherapy and occupational and speech therapy and biokinetics of a rehabilitative nature that is preceded by hospitalisation.

    Limited to R10 950 (2018) or R11 550 (2019) per family per annum

    Subject to overall annual limit of R2 100 000 (2018) or R2 200 000 (2019) per family per annum

    Such treatment must be connected to an approved rehabilitative treatment plan and must commence within two weeks of discharge from hospital.

    100% of Society rate
    Cardiac rehabilitation benefit

    Subject to preauthorisation

    The cardiac rehabilitation benefit provides for an initial three-month, intensive rehabilitation benefit followed by a three-month continuing care benefit.

    Limited to six months per cardiac event

    Subject to overall annual limit of R2 100 000 (2018) or R2 200 000 (2019) per family per annum

    100% of Society rate at accredited providers
  • Radiology
    Basic All X-rays

    Subject to preauthorisation

    In the event of an emergency, the Society's designated agent must be notified on the first working day following the procedure.

    In respect of PMB conditions, radiology must be detailed in the care plan; treatment to be paid at 100% of cost

    R1 150 (2018) or R1 200 (2019) per beneficiary per annum

    Where the treatment is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the service being rendered.

    100% of agreed tariff out-of-hospital and 100% of agreed tariff in-hospital for non-PMBs.
    PMBs are 100% of cost
    Ultrasounds

    Subject to preauthorisation

    In the event of an emergency, the Society's designated agent must be notified on the first working day following the procedure.

    In respect of PMB conditions, radiology must be detailed in the care plan; treatment to be paid at 100% of cost

    Subject to overall annual limit of R2 100 000 (2018) or R2 200 000 (2019) per family per annum

    Where the treatment is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the service being rendered.

    100% of Society rate both in and out of hospital for non-PMBs.
    PMBs are 100% of cost
    Advanced MRI and CT scans/ Scopes (diagnostics)/ Angiography/ Nuclear medicine studies

    Subject to preauthorisation

    The Society's designated agent must authorise MRI and CT scans, scopes and angiographies, except in emergencies

    Subject to overall annual limit of R2 100 000 (2018) or R2 200 000 (2019) per family per annum

    Where the treatment is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the service being rendered.

    100% of Society rate both in and out of hospital for non-PMBs.
    PMBs are 100% of cost
    PET Scans

    Subject to Authorised as part of a member's oncology treatment or where it is deemed to be clinically appropriate and medically necessary by the Society's designated agent

    Subject to overall annual limit of R2 100 000 (2018) or R2 200 000 (2019) per family per annum

    100% of Society rate both in and out of hospital for non-PMBs.
    PMBs are 100% of cost
  • Pathology
    Blood Tests

    In respect of PMB conditions, pathology must be detailed in the care plan; treatment to be paid at 100% of cost

    Subject to overall annual limit of R2 100 000 (2018) or R2 200 000 (2019) per family per annum

    100% of agreed tariff in-hospital and 80% of agreed tariff in-hospital for non-PMBs.

    100% of cost for PMBs
  • Organ transplants
    Benefit includes anti-rejection medication, but excludes hospitalisation and related costs, which are covered under the hospitalisation benefit
    Organ transplants procedures

    Subject to preauthorisation

    The Society will pay for the cost of harvesting the organ from the donor and to transplant it to the recipient if both the donor and the recipient are members of the Society.

    Where the donor is a member of the Society and the recipient is not, the costs of harvesting the organ from the donor will not be covered by the Society.

    If the recipient is a member of the Society, the harvesting costs will be covered.

    Benefit is not adjusted in proportion to the number of months of membership if member joins during benefit year.

    Limited to R180 000 (2018) or R190 000 (2019) per family per annum

    100% of agreed tariff at DSP for non-PMBs.

    100% of cost for PMBs
  • Kidney dialysis

    Subject to preauthorisation

    100% of cost
  • Blood transfusions
    Includes the cost of blood, blood equivalents, blood products and the transportation of blood

    Subject to preauthorisation

    100% of cost
  • Ambulance services
    Road and air
    Ambulance services

    Subject to authorisation from the Society's designated service provider (Netcare 911)

    Failure to obtain authorisation subject to 30% co-payment

    Such transport is to be certified by a medical practitioner as being essential.

    100% of cost at designated service provider, except in case of emergency
  • Prostheses
    External and internal
    Hip replacements

    Subject to preauthorisation by the Society's designated agent or hospital DSP

    Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

    Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

    Limits

    Bilateral total hip: R68 050 PBPA
    Total hip: R39 250 PBPA
    Partial hip: R21 850 PBPA
    Revision hip: R74 750 PBPA
    per beneficiary per annum.

    MULTIPLE EXTERNAL AND INTERNAL PROSTHESES ARE SUBJECT TO TO A COMBINED OVERALL LIMIT OF R84 900 PBPA

    100% of agreed tariff
    Knee replacements

    Subject to preauthorisation by the Society's designated agent or hospital DSP

    Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

    Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

    Limits

    Without patella: R43 400 PBPA
    With patella: R49 150PBPA
    Bilateral knee: R87 150 PBPA
    Revision knee: R75 700 PBPA
    per beneficiary per annum.

    MULTIPLE EXTERNAL AND INTERNAL PROSTHESES ARE SUBJECT TO TO A COMBINED OVERALL LIMIT OF R84 900 PBPA

    100% of agreed tariff
    Shoulder replacements

    Subject to preauthorisation by the Society's designated agent or hospital DSP

    Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

    Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

    Limits

    Total shoulder: R52 000 PBPA
    Bilateral shoulder: R66 250 PBPA
    per beneficiary per annum.

    MULTIPLE EXTERNAL AND INTERNAL PROSTHESES ARE SUBJECT TO TO A COMBINED OVERALL LIMIT OF R84 900 PBPA

    100% of agreed tariff
    Spinal fusion

    Subject to preauthorisation by the Society's designated agent or hospital DSP

    Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

    Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

    Limits

    Level 1 (without cage): R23 650 PBPA
    Level 1 (with cage): R45 050 PBPA
    Level 2 (without cage): R31 600 PBPA
    Level 2 (with one cage): R50 350 PBPA
    Level 2 (with two cages): R73 800 PBPA
    per beneficiary per annum.

    MULTIPLE EXTERNAL AND INTERNAL PROSTHESES ARE SUBJECT TO TO A COMBINED OVERALL LIMIT OF R84 900 PBPA

    100% of agreed tariff
    Artificial limbs

    Subject to preauthorisation by the Society's designated agent or hospital DSP

    Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

    Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

    Limits

    Below the knee: R22 650 PBPA
    Above the knee: R38 000 PBPA
    per beneficiary per annum.

    MULTIPLE EXTERNAL AND INTERNAL PROSTHESES ARE SUBJECT TO TO A COMBINED OVERALL LIMIT OF R84 900 PBPA

    100% of agreed tariff
    Artificial eyes

    Subject to preauthorisation by the Society's designated agent or hospital DSP

    Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

    Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

    Limits

    R22 650 PBPA

    MULTIPLE EXTERNAL AND INTERNAL PROSTHESES ARE SUBJECT TO TO A COMBINED OVERALL LIMIT OF R84 900 PBPA

    100% of agreed tariff
    Finger joint prosthesis

    Subject to preauthorisation by the Society's designated agent or hospital DSP

    Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

    Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

    Limits

    R5 600 PBPA

    MULTIPLE EXTERNAL AND INTERNAL PROSTHESES ARE SUBJECT TO TO A COMBINED OVERALL LIMIT OF R84 900 PBPA

    100% of agreed tariff
    Pacemakers

    Subject to preauthorisation by the Society's designated agent or hospital DSP

    Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

    Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

    Limits

    With leads: R47 250 PBPA
    Biventricular: R77 450 PBPA
    per beneficiary per annum.

    MULTIPLE EXTERNAL AND INTERNAL PROSTHESES ARE SUBJECT TO TO A COMBINED OVERALL LIMIT OF R84 900 PBPA

    100% of agreed tariff
    Intra Cardiac Device

    Subject to preauthorisation by the Society's designated agent or hospital DSP

    Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

    Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

    R259 200 PBPA

    MULTIPLE EXTERNAL AND INTERNAL PROSTHESES ARE SUBJECT TO TO A COMBINED OVERALL LIMIT OF R84 900 PBPA

    100% of agreed tariff
    Cardiac valves

    Subject to preauthorisation by the Society's designated agent or hospital DSP

    Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

    Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

    Limits

    R35 700 PBPA

    MULTIPLE EXTERNAL AND INTERNAL PROSTHESES ARE SUBJECT TO TO A COMBINED OVERALL LIMIT OF R84 900 PBPA

    100% of agreed tariff
    Cardiac stents with delivery system

    Subject to preauthorisation by the Society's designated agent or hospital DSP

    Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

    Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

    Limits

    R25 600PBPA

    MULTIPLE EXTERNAL AND INTERNAL PROSTHESES ARE SUBJECT TO TO A COMBINED OVERALL LIMIT OF R84 900 PBPA

    100% of agreed tariff
    Drug eluting stents

    Subject to preauthorisation by the Society's designated agent or hospital DSP

    Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

    Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

    Limits

    R32 100 PBPA

    MULTIPLE EXTERNAL AND INTERNAL PROSTHESES ARE SUBJECT TO TO A COMBINED OVERALL LIMIT OF R84 900 PBPA

    100% of agreed tariff
    Aortic aneurism repair grafts

    Subject to preauthorisation by the Society's designated agent or hospital DSP

    Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

    Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

    Limits

    R151 500 PBPA

    MULTIPLE EXTERNAL AND INTERNAL PROSTHESES ARE SUBJECT TO TO A COMBINED OVERALL LIMIT OF R84 900 PBPA

    100% of agreed tariff
    Cochlear implant

    Subject to preauthorisation by the Society's designated agent or hospital DSP

    Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

    Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

    Limits

    R236 950 PBPA

    MULTIPLE EXTERNAL AND INTERNAL PROSTHESES ARE SUBJECT TO TO A COMBINED OVERALL LIMIT OF R84 900 PBPA

    100% of agreed tariff
    Other

    Subject to preauthorisation by the Society's designated agent or hospital DSP

    Benefit is not adjusted in proportion to the number of months of membership if a member joins during benefit year.

    Where the prosthesis is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the procedure.

    Limits

    R23 450 PBPA

    MULTIPLE EXTERNAL AND INTERNAL PROSTHESES ARE SUBJECT TO TO A COMBINED OVERALL LIMIT OF R84 900 PBPA

    100% of agreed tariff