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Foundation (R18 701+) 2021

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Type of Medical Aid Plan: 
Capitation
Medical Aid Year: 
2021
Income Level: 
R18 701+
Day to day Benefits: 

Primary Care Network consists of GP, psychologist and physiotherapist: unlimited consultations. Radiology, pathology and specialist consultations through a contracted provider on referral from the Primary Care GP. Basic dentistry, including fillings and extractions and basic optometry, are subject to contracted providers and annual limits

In Hospital Benefits
Are you prepared to use designated hospitals?: 
Yes
Hospital Rate of Payment: 
Unlimited at 100% of Contracted Rate(CR)
Hospitals: 

Only at Designated Service Provider(DSP) hospitals. Subject to Scheme Protocols, hospital procedure list and option-specific exclusion list

Upfront Payments to hospitals: 

Voluntary use of a non-DSP hospital will have a co-payment of 30%, with a minimum of R7 000. Procedure co-payments may apply to admissions; full details in the 2021 brochure

Casualty / Emergency Visits: 
No Benefit for non-PMB. Unlimited for trauma and PMB. Verification of pre-authorisation within 72 hours of the event
Specialists: 
Contracted Providers at 100% of CR. Non-contracted Providers at 100% of Scheme Rate(SR)
Other healthcare professionals eg. Physio, Occupational, Dietician: 
Contracted Providers at 100% of CR. Non-contracted Providers and Physiotherapy at 100% of SR
Radiology and pathology: 
100% of CR
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
Subject to co-payments of R7 524 for a gastroscopy and R3 762 for a colonoscopy
MRI and CT scans: 
Unlimited for emergency, injury-related and trauma. Non-PMB's subject to a co-payment of R3 612. Scheme rules and Protocols apply
ICU and High Care: 
100% of CR
Dialysis: 
Unlimited at Network Provider. Subject to Scheme Protocols. Pre-authorisation required
Organ Transplants: 
Limited to PMB's only
Oncology / Cancer: 
Unlimited for PMB conditions. Non-PMB's limited to R90 459 per beneficiary per annum. Subject to ICON Network and Essential protocols. Pre-authorisation required. 40% Non-DSP co-payment
Neck and Back Operations: 
Limited to PMB's only. Subject to prosthesis sub-limit
Joint Replacements: 
Limited to PMB's only. Subject to prosthesis sub-limit
Prosthesis: 

Internal: Unlimited per family, per annum. Subject to prosthesis sub-limits and Scheme Protocols. Non-PMB's subject to overall limit of R42 136 per family, per annum

Medical and Surgical Appliances: 
Limited to R2 249 per family per annum. Scheme Protocols and appliance sub-limits apply. Must be prescribed by a registered Healthcare practitioner and a supplier registered with the Board of Healthcare Funders
Maternity Confinements: 
Normal delivery; 3 days and 2 night: Caesarean section if clinically indicated; 4 days and 3 nights. Pre-authorisation required for elective Caesarean section
In Hospital Dentistry: 
Subject to PMB's only. Pre-authorisation is required and Scheme Protocols apply
Take home Medicine: 
Maximum of 7 days supply
Rehabilitation, Hospice and Step-down facilities: 
Unlimited in lieu of hospitalisation. Subject to pre-authorisation, PMB's and DSPs
Treatment for Mental Health: 
Psychiatric disorders are limited to Network Providers and subject to PMB's and Scheme Protocols
HIV / AIDS: 
Subject to registration on the HIV Management Programme. Hospitalisation at Network Provider hospitals. Subject to Scheme Protocols and PMB's
Ambulance Service: 
Netcare 911 in an emergency
Day-to-day benefits
GP consultations: 

Primary Care Network GP consultations. Unlimited at 100% of CR. Authorisation required after 5th visit per beneficiary. Non-contracted Providers limited to 2 out-of-network visits per family at 100% of SR

Specialist consultations: 

Subject to PMB and referral from a Primary Care Network GP. Pre-authorisation required and limited to Specialist Network Providers

Acute medicine: 

Unlimited as dispensed by a Primary Care Network GP. Subject to Foundation Formulary. For non-dispensing providers, script limit is R111 per event, per beneficiary at Preferred Provider Pharmacies. Reference and Generic Reference Pricing(GRP) may apply

Over-the-counter (OTC) Medicine: 

Limited to Schedule 0-2 drugs and subject to R50 limit per event at Preferred Provider Pharmacies

Optometry benefits: 
Subject to a 24 month cycle and a Network Provider. 1 pair of spectacles with frame and eye test; single vision: R1 258 or flat top bifocal: R1 915 per beneficiary
Basic dentistry: 
Subject to Scheme Protocols, Network Providers and limited to M = R2 249, M+= R3 747. 2 check-ups, 2 emergency consults and 1 scale and polish per beneficiary per annum. Limited cover for x-rays, fillings, extractions and emergency root canal. 100% of SR
Specialised Dentistry: 
1 full set of plastic dentures per beneficiary per 4 year cycle. Subject to Scheme Protocols and Network Providers
Orthodontics: 

No benefit

MRI and CT Scans (Out of Hospital): 
PMB's only
Radiology and Pathology: 
Unlimited at network providers on referral by GP. Subject to PMB's and formulary
Pregnancy benefits: 
Subject to registration on the Maternity Programme. GP or midwife consultations only. Gynaecologists require authorisation. 2x 2D scans
Physiotherapy and Occupational Therapy day to day: 
Subject to Primary Care Network and PMB's
Chronic Conditions
Provider: 
Medipost, Dischem and Clicks pharmacies. 40% Non-DSP co-payment. Subject to registration by a Network Provider and to Foundation Chronic formulary. Reference and Generic Reference Pricing(GRP) may apply
Chronic Conditions: 

Diagnosis, treatment and care costs of 27 chronic conditions that fall under the PMB Chronic Disease List (CDL), issued by the Council for Medical Schemes. Benign Prostatic Hypertrophy and Hormone Replacement Therapy also covered as PMB's. Subject to Disease Management Protocols and pre-authorisation

Additional Chronic Conditions: 
As above
Preventative Care Benefits
Preventative Benefits: 

Screening benefit included in the Foundation Network Provider consultation. Pap smear and PSA screening for beneficiaries older than 45 years, HIV test; flu vaccine and childhood immunisations at the discretion of Foundation Network Provider. 1 fluoride treatment per beneficiary younger than 12 years

Total Contributions
Total Contribution Main Member: 
3473.00
Total Contribution Adult: 
3473.00
Total Contribution Child*: 
1191.00
Foundation R18 701+
Medical Aid Plan Name Term: 
Foundation