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HEALTH SQUARED COBALT 2019

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Medical Aid Year: 
2019
In Hospital Benefits
Hospital Rate of Payment: 
Unlimited.
Hospitals: 

Planned PMB procedures are
subject to DSP hospital networks
& co- payment for use of non-DSP
applies. Procedure co-payments
may also be applicable. Subject
to Scheme

Upfront Payments to hospitals: 

Arthroscopy R 4 000

Circumcision, Vasectomy R 3 000

Colonoscopy R 3 000

Conservative back / spine treatment R 6 000

Cystoscopy R 2 000

Dental Admissions R 3 000

Endometrial ablation R 4 000

Excision nail bed R 2 000

Gastroscopy R 5 000

Hernia Repair R 5 000

Hysterectomy R 6 000

Hysteroscopy R 6 000

Joint replacements R 12 000

Laparoscopic procedures R 4 000

Medical admission Co-pay (Including Maternity and
Psychitric admissions) R 2 500

Myringotomy R 2 500

Nasal surgery (including endoscopy) R 6 000

Non Surgical admission co-pay (Including Maternity and
Psychiatry) R 2 500

Reflux surgery R 12 000

Rotator Cuff Surgery R 10 000

Sigmoidoscopy R 1 500

Skin lesions R 2 000

Specialised radiology (MRI, CT,PET Scan ) per scan R 2 000

Spinal surgery R 12 000

Tonsillectomy and Adenoidectomy R 0

Tympanoplasty R 0

Urinary Incontinence Repair R 4 000

Use of Non-DSP Hospital (Planned PMB's) 30% (Minimum R 7 000)

Varicose veins R 4 000

 

Specialists: 
Subject to MSA Non-Contracted Providers at 100% of Scheme Rate. Contracted Providers at 100% of Contracted Rate.
Other healthcare professionals eg. Physio, Occupational, Dietician: 
Subject to MSA
Radiology and pathology: 
Subject to MSA and PMB’s
MRI and CT scans: 
R23 415 per family per annum. Subject to Scheme Protocols and PMB. Pre-auth required. Co-payment of R2 000 per incident. (In-and-out of hospital). 100% of Scheme Rate.
Dialysis: 
Covered at Network Provider. Subject to Scheme Protocols and PMB. Pre- auth required.
Organ Transplants: 
Unlimited, subject to PMB and Scheme Protocols.
Oncology / Cancer: 
Unlimited. Subject to ICON Network and standard protocols. Pre-auth required. 40% NON DSP CO payment. Biologicals and Targeted Therapies Sub limit R273 000
Neck and Back Operations: 
Limited to R59 364 per family per annum.
Joint Replacements: 
Limited to R59 364 per family per annum.
Prosthesis: 

Unlimited per family per annum. Subject to Prosthesis Sub-Limits, Scheme Protocols.

Overall Option Limit R100 000 per Event

Knee, Hip, Shoulder, Elbow, Ankle R 50 000

Medical and Surgical Appliances: 
Subject to benefit booster and PMB's
Maternity Confinements: 
Length of stay: 3 days & 2 nights.
Take home Medicine: 
Maximum of 7 days’ supply
Rehabilitation, Hospice and Step-down facilities: 
Sub Limit R15 015 per family 100% of Scheme Rate.
HIV / AIDS: 
HIV Management Programme.
International Travel Benefit: 
Limited to emergency medical cover up to R2 million per beneficiary per incident
Day-to-day benefits
GP consultations: 

Subject to MSA

Non-Contracted Providers at
100% of Scheme Rate. Contracted
Providers at 100% of Contracted
Rate.
CDL PMB consultations covered
separately. Subject to Disease

Management Protocols and pre-
auth.

Specialist consultations: 

Subject to MSA
Non-Contracted Providers at
100% of Scheme Rate. Contracted
Providers at 100% of Contracted
Rate.
CDL PMB consultations covered
separately. Subject to Disease

Management Protocols and pre-
auth.

Acute medicine: 

Subject to MSA

Optometry benefits: 
Subject to Benefit booster
Specialised Dentistry: 
Subject to Scheme protocols and MSA
Orthodontics: 

Subject to Benefit Booster rand
sub-limits of:
M R9 765
M+1 R11 865
M+2 R13 440
M+3 R16 380
M+4+ R18 375
Implants R 4 043 per Implant

MRI and CT Scans (Out of Hospital): 
R23 415 per family per annum. Subject to Scheme Protocols and PMB. Pre-auth required. Co-payment of R2 000 per incident. (In-and-out of hospital). 100% of Scheme Rate.
Radiology and Pathology: 
R23 415 per family per annum. Subject to Scheme Protocols and PMB. Pre-auth required. Co-payment of R2 000 per incident. (In-and-out of hospital). 100% of Scheme Rate.
Pregnancy benefits: 
Surgical operations & procedures Theatre fees Labour and recovery wards Ward accommodation Intensive care and high care units X-rays and pathology Ultrasound scans (other than for pregnancy) Blood transfusions 100% of Contracted Rate.
Chronic Conditions
Chronic Conditions: 

CDL CONDITIONS

ADDISON'S DISEASE, ASTHMA, BIPOLAR MOOD DISORDER, BRONCHIECTASIS, CARDIAC DYSRHYTHMIAS, CARDIAC FAILURE, CARDIOMYOPATHY, COPD, CROHN'S DISEASE, CHRONIC RENAL FAILURE, CORONARY ARTERY DISEASE, DIABETES INSIPIDUS, DIABETES MELLITUS TYPE 1, DIABETES MELLITUS TYPE 2, EPILEPSY, GLAUCOMA, HAEMOPHILIA, HIV, HYPERLIPIDAEMIA, HYPERTENSION, HYPOTHYROIDISM, MULTIPLE SCLEROSIS, PARKINSON'S DISEASE, RHEUMATOID ARTHRITIS, SCHIZOPHRENIA, SLE, ULCERATIVE COLITIS

Additional Chronic Conditions

ADHD, ALZHEIMER'S DISEASE, ANKYLOSING SPONDYLITIS, CYSTIC FIBROSIS, ENDOMETRIOSIS, GORD/GERD, GOUT, OBSESSIVE COMPULSIVE DISORDER, OSTEOPOROSIS, OSTEOARTHRITIS, PAGET’S DISEASE, PSORIASIS, WILSON’S DISEASE

Additional Chronic Conditions: 
(SUBJECT TO MSA)
Preventative Care Benefits
Preventative Benefits: 

Pro-rated for members who join during the year. (Excludes consultation) Subject to Benefit Booster

Screening Benefit:

Blood Pressure, Blood Sugar, Cholesterol, Body Mass Index, HIV Test, Mammogram (screening), Pap smears (Subject to Benefit Booster Sub Limit R 2 625 per family at Preferred provider)

PSA Testing Subject to MSA

Vaccinations:

Flu,Childhood immunisations, HPV Vaccine (Cervical cancer prevention), Oral Contraception (Subject to MSA)

Clinic Nurse Consultation Subject to Preferred Provider Only Subject to Benefit Booster 1 - 30 min consult per beneficiary 2 - 15 min Consults per beneficiary:

Additional 15 min Consult + Flu vacine 2 - 15 min per beneficiary

Mother Ante-Natal visit 2 per Beneficiary

Mother and Well Baby Consult (incl admin of Immunisation) 1 per Beneficiary

MediBooster- Subject to Registration and Self Health Assesment at Preferred Provider only Subject to Benefit Booster Sub Limit R 1 800

Total Contributions
cobalt
Monthly Medical Savings
Savings Child*: 
6132.00
Savings Adult: 
16656.00
Savings Main Member: 
17208.00
Risk Contributions
Risk Contribution Main Member: 
6829.00
Risk Contribution Adult: 
6612.00
Risk Contribution Child: 
2435.00
Medical Aid Plan Name Term: 
Any