Guide - 2018
A Brief Sizwe Medical Fund and In the late 1960s, Black (African) doctors in the Rand, which consisted of Johannesburg, Pretoria, the Eastrand, and Vereeniging, formed themselves into The S. A. Medical Discussion Group (SAMDG) which discussed matters of interest to Black doctors and their patients. The South African Medical Association was only open to white membership then. The SAMDG met once a month on a Sunday afternoon. Meetings were hosted by members at their homes. Spouses attended meetings and held their own meeting whilst members discussed the business of the day. Meetings ended with a social. The executive of the SAMDG was appointed by region to facilitate executive meetings, in 1976, the executive was from the Eastrand, it was chaired by Dr. Mzamane of Katlegong. 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 Joburg Gen. Dr. Loots suggested that it would be a good thing to register a medical aid scheme for blacks and a private hospital for blacks, he would introduce the matter to some government officials who would make the registering 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 S African society took up leadership of the group, he led the selling of the idea to black doctors to take up shares, negotiated with white business to support the initiative, and served as chairman of the group. At this time, Dr. Motlana also led various committees of the STRUGGLE which took a great deal of his time and resulted in him spending many months under detention. In 1978 The Kwacha Group was registered with 38 shareholders. Dr. Loots was the only white shareholder. He also served on the board of directors. Sizwe Medical Fund was registered, the 38 shareholders raised R3 000 000 as security to meet claims. Lesedi Clinic was to open its doors soon after Sizwe started. (Kwacha meaning Day Break in Chewa was chosen as an appropriate name for the new company). Kwacha was later changed to Sechaba Group Holdings (Pty)Ltd pg 2 Sizwe History
history of Sechaba Medical Solutions The motivation for forming the Kwacha Group To provide medical aid cover for blacks; To enable black specialists to open private practice, black specialists of the day could only work as GPs with specialist qualifications, as specialist fees were only affordable to medical aid members. Black specialists who worked in public hospitals were not recognised, they were humiliated as they could not give orders to white juniors and to white nurses of all ranks! Many black specialists elected to go into exile and practice in the USA and in Canada. To give black private patients and their doctors access to Xray, other investigations and expensive medications which were out of reach for virtually all who had no medical aid cover. To lead the black population in matters of healthcare. 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 Bonitas for black civil servents, Sanitas for Indians, and Prosano for coloured civil servents. All these schemes were to be administered by Medscheme this is certainly the reason for Bonitas being the second largest open scheme in S.A today. The first members of Sizwe were drawn from the Barlow Rand Group, from Iscor, from PUTCO and from the steel companies and coal mining companies in Witbank and Middleburg as well as motor industry workers from Port Elizabeth and Uitenhage. The initiative by our founding fathers has survived to this day!! Sizwe History 2018 Offerings Hospital Care Gomomo Care Primary Care Affordable Care Full Care Dr Tlakula Sizwe Medical Fund - Guide 2018 pg 3
2018 HEALTHCARE HOSPITAL CARE GOMOMO CARE PRIMARY CARE The Hospital Care Option offers peace of mind knowing that in the event of hospitalisation, extensive cover is available at any private hospital. In addition, the Hospital Care Option provides cover for 27 Chronic Disease List (CDL) conditions. 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 any private hospital. Covers the 27 Chronic Disease List (CDL) conditions. Primary Care Option offers good value for money with unlimited hospitalisation at any private hospital. This traditional option has generous day-to-day benefitswhich cover acute medicines GPs,specialists, radiology, pathology and more to meet the needs of any family. pg 4 2018 Healthcare Offerings - Subject to CMS approval
OFFERINGS AFFORDABLE CARE Our Affordable Care Option offers generous comprehensive cover with unlimited hospitalisation in any private hospital. It also covers additional chronic conditions with specialised dentistry and preventative benefits. This option is suitable for young and healthy families. FULL BENEFIT CARE 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. Sizwe History 2018 Offerings Hospital Care Gomomo Care Primary Care Affordable Care Full Care Sizwe Medical Fund -- Guide 2018 pg5 5
HOSPITAL CARE Offers peace of mind knowing that in the event of hospitalisation, extensive cover is available at any private hospital. pg 8 Hospital Care
Option Structure OUT OF HOSPITAL BENEFITS Major Medical; Day to day: Risk OVERALL DAY-TO-DAY LIMIT GENERAL PRACTITIONERS SPECIALISTS (excluding psychiatrists), Acute Medicine, Pathologists,Radiologists And Physiotherapists Only PMBs ACUTE MEDICINES AND PHARMACY ADVISED THERAPY (PAT) - FALLS WITHIN DAY-TO-DAY BENEFIT WITH THE FOLLOWING SUB-LIMITS General Specialist RADIOLOGY AND RADIOGRAPHY Reimbursement rate Reimbursement rate PHYSIOTHERAPY PATHOLOGY BASIC DENTISTRY SPECIALISED DENTISTRY OPTICAL BENEFITS ACCESSED THROUGH PPN MENTAL HEALTH AUXILIARY SERVICES (Chiropractic Treatment, Homeopathy) MATERNITY Subject to registration on the Sizwe Baby Programme within 24 weeks of falling pregnant Ante-natal consultations Pregnancy scans and blood tests Fertility Ante-natal consultation: 9 GP, Midwife Visits 2 Obstetrician visits 2 x 2D scans Blood tests: Two (2) Haemoglobin Measurement tests, One (1) Blood Grouping test, One (1) VDRL test for Syphilis and One (1) HIV blood test s PSYCHOLOGICAL AND PSYCHIATRIC TREATMENT Acute OTC PMB Non-PMB Limits Principal Adult Reimbursement rate Reimbursement rate MEDICATION s s CHRONIC CONDITIONS 100% negotiated tariff at Preferred Provider Network Overall limits (Annual) MSA Risk benefit per family MSA Formulary, limit per family CHRONIC BENEFITS Subject 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) IN-HOSPITAL BENEFITS (All hospital admissions must be authorised. A co-payment of R1 500 will be applied if preauthorisation was not obtained) GENERAL IN-HOSPITAL PRACTITIONER BENEFITS AND MEDICAL SPECIALIST (All hospital admissions must be authorised. A co-payment of R1 500 will 100% be applied Sizwe rate if for preauthorisation rate was not consultations obtained) and visits Reimbursement in-hospital AUXILIARY SERVICES General Overall annual limit Provider Network Top-up cover Co Payments General scopes Dietician, speech therapy, occupational therapy BENEFITS Endoscopic (Laparoscopic surgery) investigations AMBULANCE SERVICES Contracted EUROP ASSIST SA (Telephone number: 0860 11 77 99 PHYSIOTHERAPY Reimbursement Rate Pre-authorisation and managed care protocols apply Unlimited Any R1 300 R3 000 PRIVATE HOSPITALS AND NURSING HOMES (Subject to treatment and case management protocols and PMBs. Pre-authorisation required unless it is a medical emergency) Accommodation Clinical limitations and exclusions Unlimited at any private hospital None DENTISTRY (Subject to Dental Management Programme - call 0860 109 556) Conservative Dentistry Subject to pre-authorised and managed care protocols Specialised Dentistry (Subject to pre-authorisation and Dental Management Programme) Crowns and Bridges Orthodontics (Braces) Implants Partial Metal Frame Dentures Surgery No limits but subject to treatment protocols and PMB s at a DSB Managed Care protocols apply Subject to PMB, clinical protocols and pre-authorisation 100% Sizwe Rate IN-HOSPITAL BENEFITS (All hospital admissions must be authorised. A co-payment of R1 500 will be applied if preauthorisation was not obtained) No PREVENTATIVE CARE WELLNESS SCREENING CONSULTATIONS 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-Specific Antigen (PSA): once per year for males over 40 years BLOOD SUGAR, CHOLESTEROL, BLOOD PRESSURE, BMI AND HIV MATERNITY Reimbursement Rate Hospitalisation (public or private hospitals) delivery, post-natal services and midwifery R310 100% Sizwe Rate BLOOD TRANSFUSIONS AND BLOOD REPLACEMENT PRODUCTS PROSTHESIS : pre-authorisation and managed care protocols apply ONCOLOGY, subject to PMBs and annual limit of R79 490 per family, subject to an annual limit of R37 930 per family; maximum of 3 cardiac stents and 2 vascular stents per family per annum Overall limit of R320 000 per family RADIOLOGY AND RADIOGRAPHY Specialised Radiology (MRI/ CAT scan/ Anglogram) Preauthorisation and managed care protocols Interventional radiology PATHOLOGY MENTAL HEALTH Alcoholism, drug addiction, narcotism: subject to PMBs, pre-authorisation and minimum benefit package Limited to R25 270 per family Payable from the hospital limit, subject to pre-authorisation and clinical protocols 3 days withdrawal treatment and up to 21 days rehabilitation at an appropriate facility ORGAN TRANSPLANT AND RENAL DIALYSIS (subject to pre-authorisation, minimum benefit package, treatment protocols and DSP) Subject to PMB conditions and clinical protocols Limited to R200 890 per family REFRACTIVE SURGERY INCLUDING RADIAL KERATOTOMY Sizwe History 2018 Offerings Hospital Care Gomomo Care Primary Care Affordable Care Full Care Child MSA FEMALE CONTRACEPTIVES No Sizwe Medical Fund - Guide 2018 pg 9
GOMOMO CARE Provides excellent value for money. GPs, specialists and acute medicines are accessible through a selected network provider. pg 10 Hospital Care
Option Structure Provider OUT OF HOSPITAL BENEFITS Limits Out of area visits Limits Basic Radiology and pathology Specialised Radiology in and out: is R 7140 per family Major Medical; Day to day: Risk Network OVERALL DAY-TO-DAY LIMIT GENERAL PRACTITIONERS SPECIALISTS, subject to managed care rules, formulary and clinical protocols of the DSP (Designated Service Provider) Only PMBs 4 visits per year per beneficiary, within the DSP network RADIOLOGY AND PATHOLOGY Reimbursement rate Reimbursement rate Required benefits for the full year all visits subject to referreal from a GP : subject to managed care rules, formulary and clinical protocols Combined In-hospital and Out of hospital PSYCHOLOGICAL AND PSYCHIATRIC TREATMENT Only PMBs Acute MEDICATION Reimbursement rate : subject to care rules, formulary and clinical protocols of DSP OTC Limits 300 per family CHRONIC CONDITIONS (subject to pre-authorisation, registration on the chronic medicine programme, formulary and clinical protocols of the DSP) PMB 26 Non-PMB 0 R7 870 per beneficiary PHYSIOTHERAPY (Include physiotherapists, speech therapists, clinical psychologists, Podiatrist, equipment and external prosthesis) DENTISTRY (Subject to Dental Management Programme - 0860 109 556) : subject to managed care rules, formulary and clinical protocols M: R2 770 M+1: R3 190 M+2: R3 470 Limits M+3: R3 750 M+4: R4 010 M+5: R4 290 M+6: R4 710 OPTICAL BENEFITS (Subject to care rules, formulary and clinical protocols of DSP) Cycle 2 years M: R1 130 M+1: R1 300 Limit per family M+2: R1 440 M+3: R2 070 OUT OF HOSPITAL BENEFITS MATERNITY (subject to care rules, formulary and clinical protocols of DSP) Pregnancy scans 2 x 2D scans per pregnancy OTHER SERVICES (Psychologists, Speech Therapists, Clinical Psychologists, Podiologists, Equipment and External Prostheses) CHRONIC BENEFITS (Subject to pre-authorisation. Medicines: subject to registration on the Chronic Medicine Programme. PMBs subject to pre-authorisation, preferred providers and treatment protocols.) PMB Non-PMB R7 870 per beneficiary. Cover for 27 PMB chronic conditions At Cost 100% Sizwe Rate 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) Subject to PPDMP benefits include counseling, prescription medicine, pathology tests. IN-HOSPITAL BENEFITS (All hospital admissions must be authorised. A co-payment of R1 500 will be applied if pre-authorisation was not obtained) Overall annual limit Provider Network AMBULANCE SERVICES Contracted EUROP ASSIST SA (Telephone number: 0860 11 77 99 Unlimited Any BENEFITS PRIVATE HOSPITALS AND NURSING HOMES (Subject to treatment and case management protocols and PMBs. Pre-authorisation required unless it is a medical emergency) Accommodation Clinical limitations Exclusions Unlimited at any private hospital Advanced laparoscopic, reconstructive surgery, joint replacements, cardiac surgery including cardiac stents, spinal surgery, breast reconstructive surgery Refractive surgery, breast reduction, breast augmentation, Keloids, Frail Care DENTAL HOSPITALISATION (Subject to pre-authorisation, Dental Management Programme and clinical protocols subject to R1 500 co-payment) General anaesthetic Conscious sedation in rooms R2 530 per family: subject to PMBs Pre-authorisation is required, subject to managed care protocols and limited to PMBs level of care Subject to pre-authorisation and limited to PMB level of care IN-HOSPITAL BENEFITS (All hospital admissions must be authorised. A co-payment of R1 500 will be applied if pre-authorisation was not obtained) GENERAL PRACTITIONER AND SPECIALIST AUXILIARY SERVICES Dietician, speech therapy, occupational therapy PHYSIOTHERAPY for consultations and visits in-hospital Subject to clinical protocols and pre-authorisation MATERNITY (Hospitalisation [public or private hospitals] delivery, post-natal services and midwifery) BLOOD TRANSFUSIONS AND BLOOD REPLACEMENT PRODUCTS : subject to PMBs PROSTHESIS (Pre-authorisation and managed care protocols apply) ONCOLOGY R28 090 per beneficiary RADIOLOGY AND RADIOGRAPHY PATHOLOGY MENTAL HEALTH (Subject to pre-authorisation and managed care rules) Psychiatry hospitalisation Alcoholism, drug addiction, narcotism: subject to PMBs, pre-authorisation and minimum benefit package Limited to 21 days per beneficiary per annum Psychiatrist consultations and 6 in-hospital Clinical Psychologists subject to PMBs ORGAN TRANSPLANT AND RENAL DIALYSIS Restricted to PMBs, subject to pre-authorisation, minimum benefit package, treatment protocols and DSP REFRACTIVE SURGERY INCLUDING RADIAL KERATOTOMY No Sizwe History 2018 Offerings Hospital Care Gomomo Care Primary Care Affordable Care Full Care Sizwe Medical Fund - Guide 2018 pg 11
PRIMARY CARE Primary Care Option offers good value for money with unlimited hospitalisation at any private hospital, to meet the needs of any family. pg 12 Gomomo Care
Option Structure Provider OUT OF HOSPITAL BENEFITS Major Medical; Day to day: Risk Any OVERALL DAY-TO-DAY LIMIT M: R5 680 M+1: R8 410 M+2: R9 840 M+3: R11 250 M+4: R12 680 M+5: R14 100 M+6+: R15 520 GENERAL PRACTITIONERS M: 4 M+1: 9 M+2: 12 M+3: 14 M+4: 15 M+5: 16 M+6+:17 SPECIALISTS (EXCLUDING PSYCHIATRISTS) All visits subject to referral from a GP Non-referral will result in M: 2 M+1: 6 M+2: 7 M+3: 8 M+4: 9 M+5: 10 M+6+: 11 ACUTE MEDICINES AND PHARMACY ADVISED THERAPY (PAT) - FALLS WITHIN DAY-TO-DAY BENEFIT WITH THE FOLLOWING SUB-LIMITS Structure Specialised Within day to day with, sub-limits: 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 Subject to PMB chronic conditions, pre-authoristion, registration on the chronic disease prgramme formolary and clinical protocols RADIOLOGY AND RADIOGRAPHY Reimbursement Rate PHYSIOTHERAPY PATHOLOGY Subject to managed care protocols 100% Sizwe Rate R18 680 per family for in and out of hospital Subject to day to day benefits Subject to day to day benefits MENTAL HEALTH (Limited to Psychiatrist, Clinical, Counselling, Psychologist excludes services covered under Auxillary ) R5 180 per family DENTISTRY (Subject to Dental Management Programme - 0860 109 556) Limit per beneficiary 2 general check ups a year per beneficiary once in six months Motivation may be requested for extensive restorative treatment plans (fillings) Plastic dentures OUT OF HOSPITAL BENEFITS Crowns and Bridges Orthodontics (Braces) Implants Root Canal, Clinical protocols apply 1 set per jaw every 4 years SPECIALISED DENTISTRY (Subject to pre-authorisation and Dental Management Programme) Partial Metal Frame Dentures Surgery No No No No Managed Care protocols apply OPTICAL BENEFITS ACCESSED THROUGH (PPN) Cycle Limit per bb Frames Single focus lenses Bi-focal lenses Multi-focal lenses No limit 2 years Limit per beneficiary R320 R175 per lens R380 per lens R380 per lens Contact lenses R1 200 AUXILIARY SERVICES (Speech Therapists, Podiatrists, Occupational Therapists, Social Workers, Dieticians Audiologists, Chiropractors, Homeopathy, Educational Psychologists, Clinical Technologist, Biokineticist and Registered Counsellors) Reimbursement Rate 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 and 24 weeks of falling pregnant) Ante-natal consultations Pregnancy scans 9 GP/Midwife visits; 2 Specialist visits 2 x 2D scans per pregnancy CHRONIC BENEFITS (Subject to pre-authorisation. Medicines: subject to registration on the Chronic Medicine Programme. PMBs subject to pre-authorisation, preferred providers and treatment protocols.) Cover for 27 PMB chronic conditions 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) Subject to PPDMP benefits include counseling, prescription medicine, pathology tests. IN-HOSPITAL BENEFITS (All hospital admissions must be authorised. A co-payment of R1 500 will be applied if pre-authorisation was not obtained) Overall annual limit Provider Network Unlimited Any IN-HOSPITAL BENEFITS (All hospital admissions must be authorised. A co-payment of R1 500 will be applied if pre-authorisation was not obtained) AMBULANCE SERVICES Contracted EUROP ASSIST SA (Telephone number: 0860 11 77 99 BENEFITS PRIVATE HOSPITALS AND NURSING HOMES (subject to pre-authorisation and case management protocols and PMB s unless its a medical emergency) Accommodation Clinical limitations and exclusions Exclusions A co-payment will apply to all unauthorised admissions unless it is an emergency. Unlimited at any private hospital Advanced laparoscopic, reconsructive surgery, joint replacements, cardiac surgery including cardiac stents, spinal surgery, breast reconstructive surgery Refractive surgery, breast reduction, breast augmentation, Keloids, Frail Care DENTAL HOSPITALISATION (Subject to pre-authorisation, Dental Management Programme and clinical protocols subject to R1 500 co-payment on some options) General anaesthetic Laughing gas in dental rooms Conscious sedation in rooms Pre-authorisation is required, subject to managed care protocols Subject to pre-authorisation and managed care protocols GENERAL PRACTITIONER AND MEDICAL SPECIALIST General AUXILIARY SERVICES AUXILIARY SERVICES PHYSIOTHERAPY Pre-authorisation and managed care protocols apply MATERNITY Hospitalisation (public or private hospitals) delivery, post-natal services and midwifery for consultations and visits in-hospital Subject to pre authorisation and PMBs, limited to dieticians, speech therapy, occupational therapy and clinical technology BLOOD TRANSFUSIONS AND BLOOD REPLACEMENT PRODUCTS PROSTHESIS ONCOLOGY 100% of the cost of blood transfusions and blood replacement products, limited to PMBs, Subject to pre-authorisation, treatment protocols, DSPs and PMBs Maximum of 3 cardiac stents and 2 vascular stents per family per annum Annual limit: R 25 600 Sizwe History 2018 Offerings Hospital Care Gomomo Care Primary Care Care Affordable Care Full Care Sizwe Medical Fund - Guide 2018 pg 13
IN-HOSPITAL BENEFITS (All hospital admissions must be authorised. A co-payment of R1 500 will be applied if pre-authorisation was not obtained) Overall limit of R143 780 per family RADIOLOGY AND RADIOGRAPHY Specialised Radiology (MRI/CAT scan/ Anglogram) Pre-authorisation and managed care protocols Interventional radiology :subject to clinical protocols Limited to R18 680 per family per annum Payable from the hospital limit, subject to pre-authorisation and clinical protocols PATHOLOGY MENTAL HEALTH Psychiatry hospitalisation Alcoholism, drug addiction, narcotism: subject to PMBs, pre-authorisation and minimum benefit package Limited to 21 days per beneficiary per annum Psychiatrist consultations and 6 in-hospital Clinical Psychologists subject to PMBs 3 days withdrawal treatment and up to 21 days rehabilitation ORGAN TRANSPLANT AND RENAL DIALYSIS Subject to PMBs at DSPs REFRACTIVE SURGERY INCLUDING RADIAL KERATOTOMY No PREVENTATIVE BENEFITS WELLNESS SCREENING CONSULTATIONS Consultation R1 000 Subject to a family limit of R2 020 for flu vaccine and pneumococcal vaccine. Screening benefits 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-Specific Antigen (PSA): once per year for males over 40 years BLOOD SUGAR, CHOLESTEROL, BLOOD PRESSURE, BMI AND HIV R260 ORAL CONTRACEPTIVES R2 620 per family per annum OTHER BENEFITS: IN-HOSPITAL OR OUT-OF-HOSPITAL Appliances Wheelchair Hearing aids Private nursing M: R1 010 M+1+:R1 630 R1 800 per family R7 500 per family R4 540 per family pg 14 Primary Care
AFFORDABLE CARE Offers generous comprehensive cover with unlimited hospitalisation in any private hospital. This option is suitable for young and healthy families. Sizwe History 2018 Offerings Hospital Care Gomomo Care Primary Care Affordable Care Full Care Sizwe Medical Fund - Guide 2018 pg 15
Option Structure Provider OUT OF HOSPITAL BENEFITS Major Medical; Day to day: Risk Any OVERALL DAY-TO-DAY LIMIT M: R9 840 M+1: R14 100 M+2: R16 230 M+3: R17 660 M+4: R19 790 M+5: R21 930 M+6+: R23 930 GENERAL PRACTITIONERS (CARE OPTION ONLY) Chosen GP Specialised Radiology: (MRI/CAT scan/angiogram) pre-authorisation and managed care protocols Reimbursement Rate SPECIALISTS Limited number of visits M: 7 M+1: 14 M+2: 16 M+3: 18 M+4: 20 M+5: 21 M+6+: 22 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: 4 M+1: 8 M+2: 9 M+3: 10 M+4: 11 M+5: 12 M+6+:13 ACUTE MEDICINES 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 RADIOLOGY AND RADIOGRAPHY MENTAL HEALTH PHYSIOTHERAPY PATHOLOGY Subject to clinical protocols Subject to an overall combined in and out of hospital limit of R28 400 per family Limited to Psychiatrists, Clinical and Counselling Psychologists subject to R8 580 per family Risk benefit 100% Sizwe Rate Paid from the day to day limit OUT OF HOSPITAL BENEFITS DENTISTRY (Subject to Dental Management Programme - 0860 109 556) Plastic dentures Crowns and bridges Dentures Orthodontic treatment 2 general check ups a year per beneficiary Motivation may be requested for extensive restorative treatment plans (fillings) Clinical protocols apply SPECIALISED DENTISTRY Root Canal: Managed Care Protocols apply 1 Set dentures, full or partial every 4 years : Subject to pre-authorised and managed care protocols 1 Crown per family per year Partial frames per beneficiary in a 5 year period lmited to 1 beneficiary per annum Pre-authorisation and clinical protocols Restricted to beneficiary < 18 years, 35% co-pay OPTICAL BENEFITS ACCESSED THROUGH PPN Cycle Frames Single focus lenses Bi-focal lenses Multi-focal lenses 2 years Limit per beneficiary R800 R175 per lens R380 per lens R695 per lens Contact lenses R1 500 AUXILIARY SERVICES (Speech therapy; Podiatry; Occupational Therapy; Social Worker; Dietetics; Audiology, Homeopathy; Educational Psychologist; Biokineticist and Registered Counselor) Reimbursement Rate M: R 1 510 M+1+: R 2 640 MATERNITY (Subject to registration on the Sizwe Baby Programme within 24 weeks of falling pregnant) Ante-natal consultations Pregnancy scans CHRONIC MEDICINES PMB 26 Beneficiary Non PMB 9 GP/Midwife visits; 4 Specialist visits 2 x 2D scans per pregnancy R5 540 per beneficiary M: R5 540 M+1: R11 090 M+2: R16 640 M+3: R22 190 M+4: R27 730 M+5: R33 300 M+6+:R38 850 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) Subject to treatment protocols and PMBs IN-HOSPITAL BENEFITS (All hospital admissions must be authorised R1500 co-payment will be applied if authorisation was not obtained except in emergencies) Annual Limit Provider Limits AMBULANCE SERVICES General for IN-HOSPITAL BENEFITS AUXILIARY SERVICES (Dietician, Speech Therapy, Occupational Therapy) Dietician, speech therapy, occupational therapy Subject to pre authorisation and PMBs PHYSIOTHERAPY (Pre-authorisation and managed care protocols apply) MATERNITY (Hospitalisation [public or private hospitals]delivery, post-natal services and midwifery) BLOOD TRANSFUSIONS AND BLOOD REPLACEMENT PRODUCTS s; limited to PMBs PROSTHESIS (Subject to pre-authorisation, treatment protocols and PMBs) Reimbuirsement rate ONCOLOGY 100% of cost Maximum of 3 cardiac stents and 2 vascular stents per family per annum Annual limit: R42 670 R314 170 per family RADIOLOGY AND RADIOGRAPHY Specialised Radiology (MRI/CAT scan/ Anglogram) Pre-authorisation and managed care protocols Subject to pre-authorisation and managed care protocols Preferred provider network 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 protocolsand PMBs. Pre-authorisation required unless it is a medical emergency. A co-payment will apply to all unauthorised admissions unless it is an emergency.) Accommodation Clinical limitations and exclusions Unlimited at any private hospital None DENTAL HOSPITALISATION (Subject to pre-authorisation, Dental Management Programme and clinical protocols subject to R1 500 co-payment) General anaesthetic Laughing gas in dental rooms Conscious sedation in rooms Pre-authorisation is required, subject to managed care protocols Subject to pre-authorisation and managed care protocols GENERAL PRACTITIONER AND SPECIALIST consultations and visits in-hospital Limited to R28 400 per family per annum, pre-authorisation and managed care protocols Interventional radiology Payable from the hospital limit, subject to pre-authorisation and clinical protocols pg 16 Affordable Care
IN-HOSPITAL BENEFITS Psychiatry hospitalisation PATHOLOGY MENTAL HEALTH Alcoholism, drug addiction, narcotism: subject to PMBs, pre-authorisation and minimum benefit package Limited to 21 days per beneficiary per annum Psychiatrist consultations and 6 in-hospital Clinical Psychologists subject to PMBs 3 days withdrawal treatment and up to 21 days rehabilitation ORGAN TRANSPLANT AND RENAL DIALYSIS Restricted to PMBs, subject to pre-authorisation, minimum benefit package, treatment protocols and DSP REFRACTIVE SURGERY INCLUDING RADIAL KERATOTOMY OVERALL ANNUAL LIMIT Limited to R6 310 per family R6310 per family per annum PREVENTATIVE BENEFITS ORAL CONTRACEPTIVES R2 620 per family OTHER BENEFITS: IN-HOSPITAL OR OUT-OF-HOSPITAL Appliances Wheelchair (Once every four years) Hearing aids Private nursing R6 780 Limits Screening & vaccines Wellness screening Wellness consults Contraceptives Chiropractors M: R1 510 M+1+1: R2 640 Limited to R3 150 per family 12 000 Once in every 3 years PREVENTATIVE CARE Females: Mammogram every 2 years for women above age 40 years: Pap smear every 2 years for women above 21 years Males (above 40 years): Prostate-Specific Antigen test 2 020 per family 260 per beneficiary 1 470 per family 2 620 per family 1 300 per beneficiary Sizwe History 2018 Offerings Hospital Care Gomomo Care Primary Care Affordable Care Care Full Care Sizwe Medical Fund - Guide 2018 pg 17
FULL BENEFIT CARE offers comprehensive cover and generous benefits to cover families and individuals who need access to unlimited hospitalisation at any private hospital. pg 18 Affordable Care
OUT OF HOSPITAL BENEFITS OPTION STRUCTURE Provider Limits Major Medical; Day to day: Risk Any OVERALL DAY-TO-DAY LIMIT M: R16 230 M+1: R21 930 M+2: R24 650 M+3: R27 490 M+4: R30 350 M+5: R33 190 M+6+:R36 020 GENERAL PRACTITIONERS (ADDITIONAL GP VISITS PER FAMILY ON THE PRIMARY CARE OPTION ONLY) Subject to availability in day to day limits M: 12 M+1: 20 M+ 2: 25 M+3: 29 M+4: 30 M+5: 31 M+6+:32 SPECIALISTS (EXCLUDING PSYCHIATRISTS) 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 Limits Speacialists rates (MRI/ CAT scan/ Angiogram) PMB Non-PMB subject to day to day limits M: R4 620 M+1: R8 170 M+2: R9 480 M+3: R10 790 M+4: R11 480 M+5: R12 090 M+6+:R12 680 RADIOLOGY AND RADIOGRAPHY Rate Structure Limits CHRONIC CONDITIONS on general radiology R37 360 per family in-hospital and out of hospital limit Combined In-hospital and Out of hospital R37 370 per family subject to pre-authorisation preferred provider and treatment protocols 26 Chronic conditions M: R10 970 M+1: R21 960 M+2: R32 820 M+3: R43 800 M+4: R54 780 M+5: R65 760 M+6+:R76 750 PSYCHOLOGICAL AND PSYCHIATRIC TREATMENT Structure PHYSIOTHERAPY PATHOLOGY Subject to R16 540 per family Risk benefit, within day to day limit OUT OF HOSPITAL BENEFITS BASIC DENTISTRY (Conservative Dentistry: Subject to Dental Management Programme - 0860 109 556) Plastic dentures Orthodontic treatment 2 general check ups a year per bb Motivation may be requested for extensive restorative treatment plans (fillings) Clinical protocols apply Root canal: subject to managed care protocols 1 per jaw every 4 years SPECIALISED DENTISTRY 3 crowns pfpa, 2 metal frames pfpa, 2 implants per bb/ 5 years limited to R3 690 per implant Pre-authorisation and clinical protocols Restricted to bbs < 18 years OPTICAL BENEFITS ACCESSED THROUGH A CONTRACTED SERVICE PROVIDER Cycle 2 years Frames R1 000 Single focus lenses Bi-focal lenses Multi-focal lenses R175 per lens R380 per lens R695 per lens Contact lenses R1 700 MENTAL HEALTH (Psychiatrists, Clinical and Counselling Psychologists - only if related to mental health, excludes Educational Psychologists, Social Workers and Registered Counsellors) Subject to R16 540 per family AUXILIARY SERVICES (Speech Therapy; Podiatry; Occupational Therapy; Social Worker; Dietetics; Audiology; Homeopathy; Educational Psychologist; Biokineticist and Registered Counselor) M: R2 770 M+1+: R4 660 MATERNITY (Subject to registration on the Sizwe Baby Programme within 24 weeks of falling pregnant) Reimbursement Rate Pregnancy scans 100% Sizwe Rate 2 x 2D scans per pregnancy CHRONIC BENEFITS (Subject to pre-authorisation. Medicines: subject to registration on the Chronic Medicine Programme. PMBs subject to pre-authorisation, preferred providers and treatment protocols.) PMB Non-PMB subject to pre-authorisation, preferred providers and Treatment Protocols At Cost M: R10 970 M+1: R21 960 M+2: R32 820 M+3: R43 800 M+4: R54 780 M+5: R65 760 M+6+:R76 750 CHRONIC BENEFITS (Subject to pre-authorisation. Medicines: subject to registration on the Chronic Medicine Programme. PMBs subject to pre-authorisation, preferred providers and treatment protocols.) HIV/AIDS MANAGEMENT PROGRAMME (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) Annual Limits Provider General IN-HOSPITAL BENEFITS AUXILIARY SERVICES Dietician, speech therapy, occupational therapy PHYSIOTHERAPY Pre-authorisation and managed care protocols apply MATERNITY Hospitalisation (public or private hospitals) delivery, post-natal services and midwifery Subject to pre authorisation and PMBs BLOOD TRANSFUSIONS AND BLOOD REPLACEMENT PRODUCTS limit: pre-authorisation and managed care protocols apply PROSTHESIS ONCOLOGY IN-HOSPITAL BENEFITS AMBULANCE SERVICES Contracted EUROP ASSIST SA (Telephone number: 0860 11 77 99 Unlimited Any BENEFITS No limit, subject to treatment protocols and PMBs PRIVATE HOSPITALS AND NURSING HOMES (Subject to treatment and case management protocols and PMBs. Pre-authorisation required unless it is a medical emergency) Accommodation Clinical limitations and exclusions Unlimited at any private hospital None DENTAL HOSPITALISATION (Subject to pre-authorisation, Dental Management Programme and clinical protocols subject to R1 500 co-payment on some options) General anaesthetic Laughing gas in dental rooms Conscious sedation in rooms Pre-authorisation is required, subject to managed care protocols Subject to pre-authorisation and managed care protocols GENERAL PRACTITIONER AND MEDICAL SPECIALIST 100% of the cost of blood transfusions and blood replacement products, limited to PMBs 100% of cost Subject to pre-authorisation, treatment protocols and PMBs Maximum of 3 cardiac stents and 2 vascular stents per family per annum Annual limit: R56 330 Sizwe History 2018 Offerings Hospital Care Gomomo Care Primary Care Affordable Care Full Care Overall limit of R377 010 per family Sizwe Medical Fund - Guide 2018 pg 19
IN-HOSPITAL BENEFITS RADIOLOGY AND RADIOGRAPHY General reimbursement rate Specialised Radiology (MRI/CAT scan/ Anglogram) Pre-authorisation and managed care protocols Interventional radiology Limited to R37 360 per family per annum Combined in-hospital and out-of-hospital limit Payable from the hospital limit, subject to pre-authorisation and clinical protocols PATHOLOGY MENTAL HEALTH Psychiatry hospitalisation Limited to 21 days per beneficiary per annum Psychiatrist consultations and 6 in-hospital Clinical Psychologists subject to PMBs Alcoholism, drug addiction, narcotism: subject to PMBs, pre-authorisation and minimum benefit package 3 days withdrawal treatment and up to 21 days rehabilitation ORGAN TRANSPLANT AND RENAL DIALYSIS Subject to PMBs REFRACTIVE SURGERY INCLUDING RADIAL KERATOTOMY R12,120 per family per annum PREVENTATIVE BENEFITS WELLNESS CONSULTATIONS Consultation benefits R1 470 Subject to R2 875 per family for flu vaccine and pneumococcal vaccine. Screening benefits 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-Specific Antigen (PSA): once per year for males over 40 years BLOOD SUGAR, CHOLESTEROL, BLOOD PRESSURE, BMI AND HIV R260 per beneficiary ORAL CONTRACEPTIVES R2,620 per family per PREVENTATIVE BENEFITS annum OTHER BENEFITS: IN-HOSPITAL OR OUT-OF-HOSPITAL Appliances M: R2 640 M+1+:R4 400 Private nursing Limit per family 9 080 per family Chiropractors R2 000 per beneficiary pg 20 Full Care
Sizwe Medical Fund - Guide 2018 pg 21 Sizwe History 2018 Offerings Hospital Care Gomomo Care Primary Care Affordable Care Full Care Full Care
2018 HOSPITAL CARE GOMOMO CARE Contribution Income Band Contribution Income Band PRINCIPAL R1 500 All R877 R1 156 R1 649 R2 048 R0 - R7 147 R7 148 - R8 337 R8 338 - R10 719 R10 720 + ADULT R1 100 All R867 R1 156 R1 592 R1 672 R0 - R7 147 R7 148 - R8 337 R8 338 - R10 719 R10 720 + CHILD R500 All R365 R419 R458 R489 R0 - R7 147 R7 148 - R8 337 R8 338 - R10 719 R10 720 + % of total contribution paid to savings account 0% 0%
Contributions Traditional Traditional Traditional PRIMARY CARE AFFORDABLE CARE FULL BENEFIT CARE Contribution Income Band Contribution Income Band Contribution Income Band R419 R1 964 R2 396 R0 - R562 R563 - R9 292 R9 293 + R2 815 R2 928 R3 767 R0 - R15 955 R15 956 - R32 499 R32 500+ R4 336 R5 032 < R32 499 R32 500+ R419 R1 533 R1 565 R0 - R562 R563 - R9 292 R9 293 + R2 586 R2 688 R3 349 R0 - R15 955 R15 956 - R32 499 R32 500+ R3 940 R4 574 < R32 499 R32 500+ R419 R494 R494 R0 - R562 R563 - R9 292 R9 293 + R649 R680 R752 R0 - R15 955 R15 956 - R32 499 R32 500+ R886 R989 < R32 499 R32 500+ 0% 0% 0%
IMPORTANT CHRONIC MEDICATION PROGRAMME: Tel: 0860 103 455 011 353 0030 Fax: 011 353 0352/0076 Email: chronic@sizwemedfund.co.za HOSPITAL PRE-AUTHORISATION, HOSPITAL BENEFIT MANAGEMENT PROGRAMME: Tel: 0860 101 176 DENTAL BENEFIT MANAGEMENT: Tel: 0860 109 556 Fax: 0866 770 336 Email: sizweenq@denis.co.za WELLNESS PROGRAMME HELPLINE FOR ASTHMA, CARDIOVASCULAR DISEASE, DIABETES AND MENTAL HEALTH: Tel: 0860 103 455 Fax: 011 221 5238 Email: wellnessqueries@sizwemedfund.co.za pg 24 Full Care
CONTACT DETAILS HIV/AIDS MANAGEMENT PROGRAMME: Tel: 0860 103 454 Fax: 011 221 5235/56 EUROP ASSISTANCE SA, MEDICAL EMERGENCIES, 24-HOUR AMBULANCE SERVICES AND MEDICAL ADVICE: Tel: 0860 117 799 SIZWE BABY PROGRAMME: Fax: 011 221 5218 Email: sizwebaby@healthichoices.com TIP-OFFS ANONYMOUS FRAUD LINE: Tel: 0800 204 702 Fax: 0800 007 788 Email: sizwemedical@tip-offs.com CHRONIC MEDICATION PROGRAMME: Tel: 0860 103 455 011 353 0030 Fax: 011 353 0352/0076 Email: chronic@sizwemedfund.co.za Sizwe History 2018 Offerings Hospital Care Gomomo Care Primary Care Affordable Care Full Care Sizwe Medical Fund - Guide 2018 pg 25
queries@sizwe.co.za 0860 100 871