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Prosper 2021

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Type of Medical Aid Plan: 
Hybrid
Medical Aid Year: 
2021
Day to day Benefits: 

Stated benefits for Primary Care Network Provider consultations, basic dentistry and optometry. Medical Savings Account(MSA) for specialist consultations, acute and over-the-counter medication, Alternative Healthcare Services, radiology, pathology and advanced dentistry. MSA annual value of M = R4 128; Adult dependant = R3 840; Child dependant: R1 440

In Hospital Benefits
Are you prepared to use designated hospitals?: 
No
Hospital Rate of Payment: 
Unlimited at 100% of Contracted Rate(CR)
Hospitals: 

Any. Planned PMB procedures are subject to a Designated Service Provider(DSP) hospital, Scheme Protocols and option-specific exclusion list

Upfront Payments to hospitals: 

Voluntary use of a non-DSP hospital for planned PMB admissions 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: 
Unlimited for trauma and PMB. Verification of pre-authorisation within 72 hours of the event. Non-PMB subject to available MSA
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 at 100% of SR. Physiotherapy for non-PMB limited to R3 306 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 limited to R21 297 per annum, with 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. Non-PMB's limited to R308 529 per family per annum. Subject to ICON Network and Essential protocols. Pre-authorisation required. 40% Non-DSP co-payment
Neck and Back Operations: 
25% co-payment and prosthesis sub-limit of R25 475 for non-PMB surgery
Joint Replacements: 
25% co-payment and prosthesis sub-limit of R25 475 for non-PMB surgery
Prosthesis: 

Internal: Unlimited per family per annum. Subject to prosthesis sub-limits and Scheme Protocols.
Non-PMB'[s subject to overall annual limit of R25 475 per family per annum.
Coronary stents to a maximum of R25 475 for 2 stents; knee, hip, shoulder, elbow, ankle R25 475; spinal fusions per level to a maximum of R25 475; hernia mesh R8 752; intraocular lenses R3 517 per lens

Medical and Surgical Appliances: 
Limited to R4 595 per family per annum. Scheme Protocols and appliance sub-limits apply. Must be prescribed by a registered Healthcare practitioner and obtained from 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: 
Cover for impacted wisdom teeth and extensive dental procedures in children under 5 years. Co-payment of R3 762 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
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 Providers for GP, physiotherapy and psychology combined: M = 6; M+1 = 10; M+2+ = 13. Non-network GP consultations: M = 4; M+1 = 7; M+2+ = 9

Specialist consultations: 

Subject to available MSA

Acute medicine: 

Subject to available MSA, PMB's, Prosper formulary and Preferred Provider Pharmacy. Reference and Generic Reference Pricing(GRP) may apply

Over-the-counter (OTC) Medicine: 

Subject to available MSA, Prosper formulary and Preferred Provider Pharmacy. Reference and Generic Reference Pricing(GRP) may apply

Optometry benefits: 
Subject to a 24 month cycle and Network Provider. 1 pair of spectacles with frame and eye test: single vision; R1 379, or bifocal; R2 102 or multifocal; R2 557 or contact lenses; R1 379 per beneficiary
Basic dentistry: 
Subject to Scheme Protocols and annual limits of M = R3 517; M+ = R5 653. 2 check-ups, 2 emergency consultations and 2 scale and polish per beneficiary per annum. Cover for x-rays, fillings, extractions and root canal therapy at 100% of SR
Specialised Dentistry: 
Subject to available MSA
Orthodontics: 

Subject to available MSA. 1 per lifetime for individuals younger than 18 years. Benefits on pre-authorisation will be applied to cases assessed as treatment mandatory, as per orthodontic indices. No benefit for corrective jaw surgery

MRI and CT Scans (Out of Hospital): 
Unlimited for emergency, injury-related and trauma. Non-PMB limited to R21 297 per annum, with a co-payment of R3 612. Scheme rules and Protocols apply
Radiology and Pathology: 
Subject to available MSA
Pregnancy benefits: 
Subject to registration on the Maternity Programme. Consultations are subject to MSA and PMB's, 2x 2D scans
Physiotherapy and Occupational Therapy day to day: 
Primary Care Network Providers for GP. physiotherapy and psychology combined: M = 6; M+1 = 10; M+2+ = 13. Non-network providers subject to MSA
Chronic Conditions
Provider: 
Medipost, Dischem and Clicks pharmacies. 40% Non-DSP co-payment. Subject to 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: 

Limited to R2 999 per family per annum. Scheme Rate applies. Screening benefit with a sub-limit of R139 per beneficiary per annum only at a pharmacy, pap smear, mammogram for female beneficiaries older than 40 years, prostate test for males older than 45 years and HIV test. Flu vaccine, childhood immunisations and oral contraceptives are subject to available MSA

Total Contributions
Total Contribution Main Member: 
3828.00
Total Contribution Adult: 
3563.00
Total Contribution Child*: 
1339.00
Prosper
Annual Medical Savings Account
Annual Medical Savings Main Member: 
4128.00
Annual Medical Savings Adult: 
3840.00
Annual Medical Savings Child*: 
1440.00
Monthly Medical Savings
Savings Child*: 
120.00
Savings Adult: 
320.00
Savings Main Member: 
344.00
Risk Contributions
Risk Contribution Main Member: 
3484.00
Risk Contribution Adult: 
3243.00
Risk Contribution Child: 
1219.00
Medical Aid Plan Name Term: 
Any