Benefits: Hospital & Major Medical

• 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 all hospital admissions are pre-authorised.
• If you need a procedure that can be done either in a GP’s/specialist’s rooms or in hospital, opt for an in-rooms procedure, as several procedures are covered at the higher Scheme Rate if performed in the rooms rather than in hospital and the R1 500 co-payment does not apply. See further down for more information.

• 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 example, a diagnostic arthroscopy).
• 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 the Society’s Rules and the claimed amount. This difference will be debited to the member where adequate credit limit is available.
• Members are encouraged to ask service providers what their charges will be, before undergoing any test or surgery.

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. This difference will be debited to the member where adequate credit limit is available.
• You can obtain more information on SRPL rates from the Society on 053 807 3111 (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 facilities 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.

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.
 

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, a 30% co-payment will be levied on the total hospital account.

 
Please note that certain procedures and treatments performed during hospitalisation may also require pre-authorisation.

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

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/negotiated 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.
 

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 healthcare 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 benefit 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 and treatment.
 

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	Paid at Scheme Rate. The cost of in-rooms procedure are unlimited but subject to the 15-consultations limit. PRE-AUTHORISATION REQUIRED From the Society’s Managed-care department for the following in-rooms procedures: gastroscopy colonoscopy vasectomy circumcision intravitreal injection IF THE ABOVE PROCEDURES ARE DONE IN HOSPITAL: A co-payment of R1 500 will apply, as it is standard practice for these procedures to be performed in doctors’ rooms or a facility other than a hospital. Should any of the above in-rooms procedures 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, sub-acute and other facilities)	PRE-AUTHORISATION REQUIRED From the Society’s Hospital pre-authorisation department. Network Admissions – The treating providers will be paid at Scheme Rate and the hospital/facility at negotiated rates. Non-Network Admissions – The treating providers and the hospital/facility will be paid at SRPL rate. SRPL rate applies to the hospital/facility and service provider costs for all authorised non-DSP hospital, day clinic and sub-acute facility admissions. 30% co-payment on the total hospital account will be levied where pre-authorisation has not been obtained for pre-planned non-emergency admissions. A co-payment of R1 500 will apply to all arthroscopic and laparoscopic procedures performed for diagnostic purposes as well as the procedures listed in the above table. 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 – R46 100 Laparoscopic unilateral inguinal hernia – R35 950 Laparoscopic incisional/ventral hernia – R57 170 RALP (Robotic assisted laparoscopic procedure) capped overall at R169 070, being made up of the capped fee for the hospital procedure only, at R107 600, and this includes the anaesthetic time limited to a maximum of 3 hours. All the associated providers are capped at a combined total of R61 470. Managed-care protocols apply.
CONSULTATIONS
Professional fees charged by service providers	Network Admissions (including day clinics and sub-acute facilities) – The treating providers will be paid at Scheme Rate. Non-Network Admissions – The treating providers will be paid at SRPL rate. Managed-care protocols and limits apply, where applicable.
Physiotherapy, occupational therapy, speech therapy and dietician	Network Admissions – The treating providers will be paid at Scheme Rate. Non-Network Admissions – The treating providers will be paid at SRPL rate. Managed-care protocols apply.
TESTS
Pathology	Network Admissions will be paid at Scheme Rate. Non-Network Admissions will be paid at SRPL rate. Subject to a request by a medical practitioner.
Radiology (other than CT and MRI Scans)	Network Admissions will be paid at Scheme Rate. Non-Network Admissions will be paid at SRPL rate. Subject to a request by a medical practitioner.
CT and MRI Scans	PRE-AUTHORISATION REQUIRED From the Society’s Hospital pre-authorisation department. Paid at 100% of SRPL rate. Limited to 3 scans. Managed-care protocols apply.
MEDICINE
Hospital medicines	Paid at 100% of Single Exit Price (SEP). TTO medicine up to a maximum of 7 days’ supply on discharge.
MATERNITY
Home confinement or natural birth delivery	PRE-AUTHORISATION REQUIRED From the Society’s Managed-care department. Paid at 100% of 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. Network 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. Limited to 2 days’ hospitalisation for normal delivery and 3 days’ hospitalisation for a caesarean delivery. Managed-care protocols apply.
EYE CARE
Corneal transplants	PRE-AUTHORISATION REQUIRED From the Society’s Hospital pre-authorisation department. Network 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. Graft benefit limited to R13 480. Harvesting cost limited to a maximum of R17 530. Managed-care protocols apply.
Cataract removal	PRE-AUTHORISATION REQUIRED From the Society’s Hospital pre-authorisation department. Paid at 100% of 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 accessible, 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. Network Admissions (including day clinics and sub-acute facilities) – 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. This is limited to single vision lenses to a maximum of R3 730 per lens. Managed-care protocols apply.
Refractive surgery	PRE-AUTHORISATION REQUIRED From the Society’s Hospital pre-authorisation department. Network Admissions – The treating providers will be paid at 50% of Scheme Rate and the hospital at 50% of the negotiated rates. Non-Network Admissions – The treating providers and the hospital will be paid at 50% of SRPL rate. 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. Network Admissions (including in-rooms procedures) – 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. This excludes surgery in preparation for osseo-integrated implants and orthognathic surgery. 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 R12 250. The provider must be registered with the Board of Healthcare Funders.
Wound care	PRE-AUTHORISATION REQUIRED From the Society’s Managed-care department. Paid at 90% of SRPL rate. Limited to R12 250.
Hospice care	PRE-AUTHORISATION REQUIRED From the Society’s Managed-care department. Subject to PMB. Pre-authorisation of 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 R337 240. 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.
All Biologicals	Limited to R271 380 (combined sub-limit for Chronic medicine and Oncology). Subject to available limit for oncology treatment. Managed-care protocols apply.
PET and related CT planning scans	PRE-AUTHORISATION REQUIRED From the Society’s Managed-care department. Paid at 100% of SRPL rate. Subject to available limit for oncology treatment. 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 R59 450 (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 – R59 450 Spinal prosthesis – R59 450 Coronary & vascular stents, pacemakers, aortic & mitral valve replacements – R59 450 Mesh (Gortex slings and Permacol®) – R16 950 Managed-care protocols apply.
Artificial limbs (including prosthetic eyes)	PRE-AUTHORISATION REQUIRED From the Society’s Managed-care department. Paid at 90% of the cost as approved by the Society. Limited to R59 500. Repairs and maintenance are included in the limit, to a sub-limit of 15% of the limit. The benefit applies over a five-year cycle (starting from 1 January 2021). 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 SRPL or Scheme Rate. Managed-care protocols apply.
MENTAL HEALTH
Psychiatric hospitalisation for mental disorders and alcohol and/or drug dependency in-hospital rehabilitation	PRE-AUTHORISATION REQUIRED From the Society’s Hospital pre-authorisation department. 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. Managed-care protocols apply. Psychiatric Hospital Admissions: Limited to 21 days per year, provided that the treatment of PMB conditions are limited as per Annexure A of the Regulations made in terms of the Act. Alcohol and Drug Dependency Admissions: Limited to 24 days provided that the treatment of PMB conditions are limited as per Annexure A of the Regulations made in terms of the Act.
HEARING
Cochlear implants	PRE-AUTHORISATION REQUIRED From the Society’s Hospital pre-authorisation department. Paid at SRPL or Scheme Rate. Device limit of R309 100 for internal and external components only, per lifetime. Replacement & repair of the external processing system will be paid from the Hearing Aid benefit, of which the limit applies over a five-year cycle starting from 1 January 2021 (see page 28 of the MEMBER GUIDE for more information). Managed-care protocols apply.
OTHER
Blood transfusion	Paid at SRPL rates. Unlimited.