Gomomo Care - 2018
A Brief history of Sizwe Medical Fund and Sechaba Medical Solutions In the late 1960s, black (African) doctors in the Rand, which consisted of Johannesburg, Pretoria, the Eastrand and Vereeniging formed themselves into The South African Medical Discussion Group (SAMDG). The group discussed matters of interest in respect of black doctors and their patients, as the South African Medical Association (SAMA) was only open to white membership then. Black specialists could only work as General Practitioners (GPs) with specialist qualifications, as specialist fees were only affordable to medical aid members. Black specialists who worked in public hospitals were not recognised, but were humiliated as they could not give orders to white juniors and white nurses of all ranks. Many black specialists elected to go into exile and practice in the United States of America (USA) and in Canada. The SAMDG met once a month on a Sunday afternoon, hosted by members at their homes. Spouses attended meetings and held their own meeting while members discussed the business of the day. In 1976, the SAMDG which was chaired by Dr. Mzamane of Katlehong in the Eastrand appointed its executive team. It was in 1976 that Dr. Mokgesi who had a practice in Sebokeng, met a white colleague, Dr. Loots at a clinical meeting at the Johannesburg General Hospital. He suggested that it would be good to register a medical aid scheme and a private hospital for blacks. He introduced the matter to some government officials who would make registration of a black company in the urban areas possible, as this was not permissible then. The matter of a medical aid scheme and a private hospital for blacks was discussed by the SAMDG and accepted. Dr. Motlana, who was very influential in black circles and highly respected by business leaders and politicians of all sectors of South African society, assumed leadership of the group. In serving as the chairman of the group, he sold the idea to black doctors to take up shares and negotiated with white business to support the initiative. pg 2
In 1978, the Kwacha Group (Kwacha meaning Day Break in Chewa - a Malawian language) was registered with 38 shareholders. Dr. Loots was the only white shareholder and also served on the board of directors. Sizwe Medical Fund was registered after shareholders had raised R3 million as security to meet medical claims. Lesedi Clinic opened its doors soon after Sizwe Medical Fund started operating. The Kwacha Group was later changed to Sechaba Group Holdings (Pty)Ltd. The motivation for forming the Kwacha Group To provide medical aid cover for Blacks To lead the black population in matters of healthcare To enable black specialists to open private practice To give black private patients and their doctors access to X-rays, other investigations and expensive medications which were out of reach for virtually all who had no medical aid cover Although Dr. Motlana tried to persuade the powers that be to allow black civil servants of the day to join Sizwe, the government refused and instead registered other medical schemes to cater for various civil servants races. The first members of Sizwe Medical Fund were drawn from the Barlow Rand Group, Iscor, PUTCO, steel companies and coal mining companies in Witbank and Middleburg as well as motor industry workers from Port Elizabeth and Uitenhage. Forty years later, the initiative by our founding fathers continues to thrive. pg 3 Dr Tlakula
GOMOMO CARE This is our entry-level option. Gomomo care option provides excellent value for money. GPs, specialists and acute medicines are accessible through a selected network provider dentistry, radiology and pathology are also available from a network provider. No overall limit for hospitalisation at a private hospital. Covers the 27 Chronic Disease List (CDL) conditions. pg 4 2018 Healthcare Offerings - Subject to CMS approval
Option Structure Provider OUT OF HOSPITAL BENEFITS Limits Out of area visits Limits Basic Radiology and pathology Specialised (Advanced) Radiology in and out: Benefit 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) Subject to managed care rules, formulary and clinical protocols of the DSP 4 visits per year per beneficiary, within the DSP network RADIOLOGY AND PATHOLOGY Reimbursement rate Reimbursement rate PSYCHIATRIC TREATMENT Subject to referreal from a GP : subject to managed care rules, formulary and clinical protocols Combined In and Out of Hospital Only PMBs Acute Over the Counter (OTC) MEDICATION Reimbursement rate Limits : subject to managed care rules, formulary and clinical protocols of DSP R300 per family CHRONIC CONDITIONS (subject to pre-authorisation, registration on the chronic disease management programme, formulary and clinical protocols of the DSP) PMB 26 Non-PMB R7 870 per beneficiary No benefit DENTISTRY (Subject to Dental Management Programme - 0860 100 871) (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 managed care rules, formulary and clinical protocols of DSP) R490 per beneficiary Frames subject to family limits below Cycle Limit per family 2 years M: R1 130 M+1: R1 300 M+2: R1 440 M+3: R2 070 OTHER SERVICES (Physiotherapists, Speech Therapists, Clinical Psychologists, Podiatrists, Equipment and External Prostheses) CHRONIC BENEFITS (Subject to pre-authorisation. Medicines: subject to registration on the Chronic Disease Management Programme. PMBs subject to pre-authorisation, preferred providers and treatment protocols.) Non PMB PMB R7 870 per beneficiary. Cover for 27 PMB chronic conditions (inclusive of HIV/ AIDS) HIV/AIDS (Members are encouraged to register with the HIV/AIDS Management Programme. This benefit includes relevant consultations, counselling, medication and the cost of blood tests for monitoring purposes) Subject to Preferred Provider Disease Management Programme (PPDMP) benefits include counseling, prescription medicine, pathology tests and relevant consultations 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 Accommodation Unlimited BENEFITS Contracted network PRIVATE HOSPITALS AND NURSING HOMES (Subject to treatment, case management protocols and PMBs. Pre-authorisation required unless it is a medical emergency) Clinical limitations Exclusions OUT OF HOSPITAL BENEFITS MATERNITY (ANTENATAL CARE) (subject to managed care rules, formulary and clinical protocols of DSP) Pregnancy scans and blood tests 2X2D scans Blood tests: 2 Haemoglobin Measurement tests, 1 Blood Grouping test, 1 VDRL test for Syphilis and 1 HIV blood test R2 530 per family: subject to PMBs Unlimited at a private hospital Advanced laparoscopic, reconstructive surgery, joint replacements, cardiac surgery including cardiac stents, spinal surgery, breast reconstructive surgery Refractive surgery including radial keratotomy, breast reduction, breast augmentation, keloids, frail care Conscious sedation in rooms DENTAL HOSPITALISATION Limited to PMB level of care Subject to pre-authorisation and limited to PMB level of care 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) R28 090 per beneficiary ONCOLOGY (subject to pre-authorisation, treatment protocols and PMBs) RADIOLOGY AND RADIOGRAPHY (Subject to Hospital Benefit Management Programme and Disease Management Programme. Limited to PMB level of care) PATHOLOGY (Subject to Hospital Benefit Management Programme and Disease Management Programme) MENTAL HEALTH (Subject to pre-authorisation and managed care rules) Psychiatry hospitalisation Alcoholism, drug addiction, narcotism: subject to PMBs, pre-authorisation and minimum benefit package Limited to 21 days per beneficiary including 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 IN HOSPITAL BENEFITS Subject to Prescribed Minimum Benefit at DSP REFRACTIVE SURGERY INCLUDING RADIAL KERATOTOMY No Benefit pg 5
2018 Contributions GOMOMO CARE PRINCIPAL ADULT CHILD % of total contribution paid to savings account Income Band R0 - R7 147 R7 148 - R8 337 R8 338 - R10 719 R10 720 + R0 - R7 147 R7 148 - R8 337 R8 338 - R10 719 R10 720 + R0 - R7 147 R7 148 - R8 337 R8 338 - R10 719 R10 720 + Contribution R845 R1 178 R1 681 R2 087 R835 R1 178 R1 623 R1 704 R352 R427 R467 R499 0%
IMPORTANT CONTACT DETAILS 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 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 pg 7
queries@sizwe.co.za 0860 100 871