053 807 3111

Benefits: Hospital & Major Medical

What would typically qualify as hospital/major medical expenses?

In contrast to day-to-day medical healthcare needs such as visiting a doctor or a dentist, there are sometimes medical events that are more serious and costly. These would be, for example, surgical procedures, rehabilitation after a car accident, treatment for cancer and other medical treatments that most people would struggle to pay for, if they do not have medical aid. It is in terms of these costs that medical aids offer members the most peace of mind.

Not all these services take place in a hospital – for example, in-rooms procedures such as colonoscopies, and many of the expensive treatments for cancer (under the oncology benefit) take place out of hospital.

On the other hand, just because you are obtaining a medical service inside a hospital building (for example, visiting the Emergency Rooms (ER), or the pathologists), does not mean that such a service will be covered in terms of your hospital benefits, as it may form part of your dayto- day benefits, instead. (A visit to the emergency rooms [ER] that is of a serious nature and results in admission to hospital would qualify under hospital/major medical benefits.)

This chapter outlines the hospital/major medical expenses covered by the Society.
 

How can I avoid spending unnecessary money on hospital/major medical costs?

  • Use one of the Society’s Network Hospitals for procedures to enjoy higher cover. See further down for more about how Network Hospitals will save you money.
  • Make sure that any hospital admissions are preauthorised.
  • If you need a procedure that can be done either in a GP’s or specialist’s rooms or in hospital, opt for an in-rooms procedure, as a number of procedures are covered at the higher Scheme Rate if performed in the rooms rather than in hospital. See further down for more information.

What are Network Hospitals, and why should I use them?

  • A Network Hospital is a DSP with which the Society has negotiated and agreed rates*.
  • The Society has DSP arrangements with several hospitals throughout Southern Africa.
  • Members using such hospitals will not be liable for hospital co-payments, except where co-payments are noted (for diagnostic arthroscopy, for example).
  • Members are encouraged to always make use of Network Hospitals, as failure to do so will result in the member being liable for co-payments.

*Please note that the agreed rates only relate to hospital costs. Co-payments may apply to claims by other service providers (physician, physiotherapist, etc.) while in hospital.

Hospital and Service provider benefit payments in a Network Hospital

  • The hospital claim will be paid at the negotiated rate.
  • Service providers (Specialist, GP, Anaesthetist, etc.) will be paid at Scheme Rate.
  • The Scheme Rate means the rate at which the Society pays benefits to all service providers for services rendered in Network Hospitals. The Scheme Rate is limited to 165% of the SRPL rate.
  • Where service providers charge more than the Scheme Rate, the member will be responsible for paying the difference between the benefit provided by the Society in terms of its Rules and the claimed amount.
  • Members are encouraged to ask service providers what their charges will be, before undergoing any test or surgery.
  • Such excess will be debited to the member where adequate member credit is available.
You can access an up-to-date list of Network Hospitals on our website, or call 0800 111 669 to find out where your nearest Network Hospital is.

 

Hospital and Service provider benefit payments in a NON-NETWORK Hospital

  • The hospital claim will be paid at the lower SRPL rate and co-payments will apply
  • Service providers (Specialist, GP, Anaesthetist, etc.) will be paid at the lower SRPL rate, should the provider charge the SRPL rate the claim will be paid in full by the Society.
  • Should Service providers charge more than SRPL, the member will be liable for the co-payment.
  • Ask the doctors/service providers what they will charge in comparison to the SRPL rates, negotiate with all your service providers to charge the SRPL rate if they quote a higher rate. If you are not successful, consider using a Network Hospital as you will be personally liable for all the additional costs over and above the SRPL rate.
  • Such excess will be debited to the member where adequate member credit is available.
  • You can obtain more information on SRPL rates from the Society on 053 807 3111 (Call centre option 5).

Overcharges by providers

Where a provider overcharge is identified as excessive by the Society, the Society will pay only its liability directly to the Service Provider (benefit due) and the member must settle the difference directly with the service provider.

Members are encouraged to check their weekly/monthly statements to identify whether a service provider has been paid in full by the Society or whether they are required to pay the service provider directly.

Hospital benefits in other facilities

Pre-authorised admissions to day clinics, step-down facilities and other forms of care are not impacted by the above restriction regarding admissions to non-Network Hospitals, and payments to these service providers will be at the Scheme Rate. Co-payments may however still apply under certain circumstances, for example an admission for a day procedure that converts to an overnight stay in a non-Network Hospital or providers charging more than the Scheme Rate.

Psychiatric benefits

Network or Registered Psychiatric Admissions – The treating providers will be paid at Scheme Rate and the hospital at negotiated rates.

Non-Network Admissions – The treating providers and the hospital will be paid at SRPL rate.
 

How does pre-authorisation work?

Pre-authorisation means obtaining prior approval for any planned admission to a hospital, planned procedures or other benefits as defined in the benefits table.

Pre-authorisation should be obtained at least five working days prior to the date of service (for example, hospital admissions, CT scans, oncology treatment, procedures, or wheelchairs) by contacting the Society’s relevant pre-authorisation department – see contact details. Where an admission has not been pre-authorised in the case of a pre-planned non-emergency admission, a 30% co-payment will be levied on the total hospital account.

BUT WHAT IF IT IS AN EMERGENCY?
In the case of emergency hospitalisation, the Society must be notified within 24 hours or on the first working day after such admission.

 
Any associated treatment or procedures performed during hospitalisation must also be pre-authorised.

Authorisation is not a guarantee of payment, and is subject to the patient being a valid member/dependant of the Society on the date of admission. Payment for services rendered will be made in accordance with the Society’s registered rules and is at all times subject to the Society’s protocols, clinical review, negotiated rates and available benefits on the date of admission.

 

What if the procedure can be done in the doctor's rooms?

Certain medical procedures can be performed in a doctor’s consultation room and it is therefore not necessary for members to endure the inconvenience of being admitted to hospital.

No authorisation is required for minor (non-booked) in-rooms procedures, but please contact the Society’s claims department if you require clarification.

See What are the hospital/major medical benefits and benefit limits for 2021? for more information on the procedures typically covered and that require pre-authorisation.
 

How do benefits for day procedures work?

A same day hospital admission, if authorised as such, will qualify for benefits at the Scheme Rate if the admission and discharge occur on the same day without any overnight stay.

If an admission to a non-Network Hospital for a day procedure subsequently results in an overnight stay, the entire account will change from the Scheme Rate to the SRPL rate and the member will be liable for any difference in costs between that charged for a day admission and the actual final account rendered, based on the actual time and date of discharge.

Members are encouraged to ensure that, if they are admitted for a day procedure in a non-Network Hospital, their doctor performs the procedure early enough on the day in question. This will ensure that an overnight stay is not required due to the need to recover from the anaesthetic administered or for any other purpose and will thus avoid any additional co-payments being applied.
 

What are Managed-care protocols?

Many of the benefits in the table that follows are subject to managed-care protocols. Managed-care protocols are strategies employed by medical schemes and their health-care service providers to offer appropriate benefits to members in a cost-effective way. These include, for example, having medicines lists, requiring preauthorisation before certain procedures or admission to hospital, setting certain financial limits up to which the scheme will pay, or prescribing certain treatment ‘recipes’ that healthcare providers should follow for specific conditions; based on evidence-based medicine.
 

What are the benefits and benefit limits for hospital/major medical benefits for 2022?

See the table that follows. Unless otherwise specified, limits in this table are per beneficiary per benefit year.

If you are uncertain about any of these benefits, and would like to find out more, please call 053 807 3111 (Option 5).

IN-ROOMS PROCEDURES
GP and specialist in-rooms procedures
  • PRE-AUTHORISATION REQUIRED From the Society’s Managed-care department
  • Paid at SRPL rate.
  • The following in-rooms procedures will be reimbursed at the Scheme Rate:

    • gastroscopy
    • colonoscopy
    • vasectomy
    • circumcision
    • intravitreal injection
    • The in-rooms procedure costs are unlimited but subject to the 15 consultations limit per beneficiary.

 
IF THE ABOVE PROCEDURES ARE DONE IN HOSPITAL

  • A co-payment of R1 500 will apply to any of the above procedures if performed in hospital, as it is standard practice for these procedures to be performed in doctors’ consultation rooms.
  • Should any of the above in rooms procedure take place while the patient is in hospital, the Society at its discretion may waive the co-payment.
  • Where two or more of the above procedures are performed simultaneously in hospital, only one co-payment will be applied.
HOSPITALISATION
Hospitalisation
(including day cases, fixed-fee cases for cataracts, in-rooms procedures instead of hospitalisation, and alternative facilities)
  • PRE-AUTHORISATION REQUIRED From the Society’s pre-authorisation department
  • Negotiated Rate applies to DSP Network Hospital authorisations, day clinics, fixed-fee cataract procedures and sub-acute facilities.
  • Scheme Rate applies to all service providers providing their services at Network Hospitals.
  • A co-payment of R1 500 will apply to all arthroscopic and laparoscopic procedures performed for diagnostic purposes.
  • The following laparoscopic procedures may be authorised in terms of the Society’s protocols but will be subject to a capped overall benefit limit (inclusive of all hospital costs):

    • Laparoscopic-assisted vaginal hysterectomy – R41 300
    • Laparoscopic unilateral inguinal hernia – R32 210
    • Laparoscopic incisional/ventral hernia – R51 220
    • RALP (Robotic assisted laparoscopic procedure) capped overall at R151 470.
  • Managed-care protocols apply.
CONSULTATIONS
Professional fees charged by service providers in hospital
  • Scheme Rate applies to service providers where authorisation has been provided for a Network Hospital admission, as well as for day clinics and sub-acute facilities.
  • The SRPL rate applies to all voluntary non-Network Hospital admissions for hospital and service provider claims.
  • Managed-care protocols and limits apply, where applicable.
Physiotherapy, occupational therapy, speech therapy and dietician
  • Paid at Scheme Rate (if Network Hospital is used), or SRPL rate (if non-Network Hospital is used).
  • Managed-care protocols apply.
TESTS
Pathology
  • Paid at Scheme Rate (if Network Hospital is used), or SRPL rate (if non-Network Hospital is used).
  • Subject to a request by a medical practitioner.
Radiology (other than CT and MRI Scans)
  • Paid at Scheme Rate (if Network Hospital is used), or SRPL rate (if non-Network Hospital is used).
  • Subject to a request by a medical practitioner.
  • No benefit for bone density scans in hospital.
CT and MRI Scans
  • PRE-AUTHORISATION REQUIRED From the Society’s Hospital pre-authorisation department
  • Paid at SRPL rate.
  • Limited to 3 scans per beneficiary per year.
  • Managed-care protocols apply.
MEDICINE
Hospital medicines
  • Benefit is Single Exit Price (SEP).
  • TTO medicine (take home medicine) up to a maximum of 7 days’ supply.
MATERNITY
Home confinement or natural birth delivery
  • PRE-AUTHORISATION REQUIRED From the Society’s Managed-care department
  • Paid at SRPL rate.
  • Limited to the in-hospital maternity benefit costs.
  • Managed-care protocols apply.
Delivery in hospital
  • PRE-AUTHORISATION REQUIRED From the Society’s Hospital pre-authorisation department
  • Benefit is Scheme Rate (if Network Hospital is used), or SRPL rate (if non-Network Hospital is used).
  • Limited to 2 days’ hospitalisation for normal delivery and 3 days’ hospitalisation for a caesarean delivery.
  • Managed-care protocols apply.
SIGHT
Corneal transplants
  • PRE-AUTHORISATION REQUIRED From the Society’s Hospital pre-authorisation department
  • Paid at Scheme Rate (if Network Hospital is used), or SRPL rate (if non-Network Hospital is used).
  • Graft benefit limited to R12 080.
  • Harvesting cost limited to a maximum of R15 710.
  • Managed-care protocols apply.
Cataract removal
  • PRE-AUTHORISATION REQUIRED From the Society’s Hospital pre-authorisation department
  • Benefit is the cost as approved by the Society.
  • The Society will pay for one post-operative cataract consultation per year.
  • If an optometrist refers a beneficiary for a cataract examination by an ophthalmologist, the prescription may not be completed until the outcome of the referral is known. Should the optometrist prescribe and dispense spectacles before any surgery that may subsequently be performed, then the beneficiary will not qualify for additional optical benefits post-surgery within the 24-month optical benefit cycle.
  • Preferred providers contracted specifically for cataract procedures should be first choice. Should a preferred provider not be within a 25km radius of the beneficiary’s residential address, then a DSP Network hospital is to be used.
  • Managed-care protocols apply.
Intra-ocular lenses
  • PRE-AUTHORISATION REQUIRED From the Society’s Hospital pre-authorisation department
  • Benefit is the cost as approved by the Society, limited to single vision lenses and to a maximum of R3 340 per lens.
  • Managed-care protocols apply.
Refractive surgery
  • PRE-AUTHORISATION REQUIRED From the Society’s Hospital pre-authorisation department
  • Benefit for hospital and associated provider costs is 50% of Scheme Rate (if Network Hospital is used, or if done in rooms) or 50% of SRPL rate (if non-Network Hospital is used).
  • Limited to one procedure per eye per lifetime.
  • Lenses limited to single vision lenses.
  • Including but not limited to Excimer Laser and eye surgery required for astigmatism, hypermetropia, presbyopia, myopia and hypermyopia.
  • Managed-care protocols apply.
ORAL SURGERY
Maxillofacial and oral surgery
  • PRE-AUTHORISATION REQUIRED From the Society’s Hospital pre-authorisation department
  • Benefit for hospital and associated provider costs is paid at Scheme Rate (if pre-authorised and Network Hospital is used, or if done in rooms) or SRPL rate (if pre-authorised and non-Network Hospital is used).
  • This excludes surgery in preparation for osseo-integrated implants and orthognathic surgery
  • Managed-care protocols apply.
MENTAL
Psychiatric hospitalisation (including alcohol and drug dependency in-hospital rehabilitation)
  • PRE-AUTHORISATION REQUIRED From the Society’s Hospital pre-authorisation department
  • Limited to 21 days per beneficiary per year, provided that the treatment of PMB conditions is limited as per Annexure A of the Regulations.
  • Paid at Negotiated Rate (if Network Hospital or registered mental health hospital is used), or SRPL rate (if non-Network Hospital is used).
  • Limited to 24 days per beneficiary per year provided that the treatment of PMB conditions are limited as per Annexure A of the Regulations.
  • Paid at Negotiated Rate (if pre-authorised and Network Hospital or Rehabilitation hospital is used), or SRPL rate (if non-Network Hospital is used).

 

For both admissions above the following will apply:

  • Scheme Rate will apply to providers treating patients in Network and registered psychiatric hospitals.
  • For admissions to non-Network Hospitals, the SRPL rate will apply to the treating provider as well as the hospital.
  • Managed-care protocols apply.
NURSING
Private nursing
  • PRE-AUTHORISATION REQUIRED From the Society’s Managed-care department
  • Paid at 90% of SRPL rate.
  • Limited to R10 970.
  • The provider must have a registered practice number.
Wound care
  • PRE-AUTHORISATION REQUIRED From the Society’s Managed-care department
  • Paid at 90% of SRPL rate.
  • Limited to R10 970.
Hospice care
  • PRE-AUTHORISATION REQUIRED From the Society’s Managed-care department
  • Paid at 100% of SRPL rate, subject to PMB
  • Treatment plan is required
ONCOLOGY
Treatment in and out of hospital
  • PRE-AUTHORISATION REQUIRED
  • For in-hospital treatment, from the Society’s Hospital pre-authorisation department;
  • For out-of-hospital treatment, Society’s Managed-care department
  • Benefit is according to the ICON Advanced Option.
  • Limited to R302 140.
  • Should an ICON provider not be used, the consultation and treatment will be limited to 80% of the SPRL rate and accrue to the Oncology benefit.
  • If you do not obtain your oncology medicine from one of the Society’s DSPs, a 30% out-of-network co-payment will be applied.
  • All parenteral medicine for oncology treatment must be obtained from Dis-Chem Direct and comply with normal MRP and Formulary rules.
  • 6 follow-up visits are provided for at an ICON provider.
  • ICON protocols apply.
PET and related CT planning scans
  • PRE-AUTHORISATION REQUIRED From the Society’s Managed-care department
  • Paid at SRPL rate.
  • Accrues to Oncology benefit limit.
  • ICON protocols apply.
PROSTHESIS/TRANSPLANTS
Internal prosthesis
  • PRE-AUTHORISATION REQUIRED From the Society’s Hospital pre-authorisation department
  • Paid at the cost as approved by the Society.
  • Limited to an overall benefit of R53 260 per beneficiary (inclusive of bone cement, cages, screws, plates, coronary and vascular stents, pacemakers, aortic and valve replacements).
  • The overall annual limit is cumulative for all the sub-limits below:

    • Joint replacements – R53 260
    • Spinal prosthesis – R53 260
    • Coronary & vascular stents, pacemakers, aortic & mitral valve replacements – R53 260
    • Mesh (Gortex slings and Permacol®) – R15 190
  • Managed-care protocols apply.
Renal dialysis
(applicable to PMB-confirmed cases only)
  • PRE-AUTHORISATION REQUIRED From the Society’s Managed-care department
  • Paid at 100% of DSP Rate in and out of hospital.
  • Managed-care protocols apply.
Organ transplants
(applicable to PMB-confirmed cases only)
  • PRE-AUTHORISATION REQUIRED From the Society’s Managed-care department
  • Paid at Scheme Rate (if pre-authorised and Network Hospital is used), or SRPL rate (if pre-authorised and non-Network Hospital is used).
  • Managed-care protocols apply.
HEARING
Cochlear implants
  • PRE-AUTHORISATION REQUIRED From the Society’s Hospital pre-authorisation
  • Paid at SRPL or Scheme Rate.
  • Device limit of R276 920 for internal and external components only.
  • Replacement & repair of the external processing system will be paid from the Hearing Aid benefit.
  • Managed-care protocols apply.
OTHER
Blood transfusion
  • Paid at SRPL rate.
  • Unlimited.

Other Benefits

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