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Resolution Health FOUNDATION R4 841 - R7 470 - 2018

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Type of Medical Aid Plan: 
Capitation
Medical Aid Year: 
2018
Income Level: 
R4 841 - R7 470
Day to day Benefits: 

Stated benefits as per limits indicated.

In Hospital Benefits
Are you prepared to use designated hospitals?: 
Yes
Hospital Rate of Payment: 
100% of Scheme Rate.
Hospitals: 

Unlimited, only at DSP network hospitals.

R4110 co-payment applicable for non-DSP hospitals.

Procedure co-payments may also be applicable.

Subject to Scheme Protocols and option specific exclusion list.

Upfront Payments to hospitals: 

Procedures only funded for prior proven PMB conditions, and strictly subject to Scheme Rules and Protocols.

Co-payments will remain applicable for hospitalisation if benefits are appropriate for out of hospital access, and where an alternative procedure that does not incur the co-payment is available.

Benefits restricted to DSP providers at DSP network hospitals.

Additional R4 110 co-payment applicable for non-DSP hospitals.

Casualty / Emergency Visits: 
No benefit.
Specialists: 
Clinical medical specialist fees, including consultations and procedures. Non-Contracted Providers at 100% of Scheme Rate. Contracted Providers up to 150% of Contracted Rate.
Other healthcare professionals eg. Physio, Occupational, Dietician: 
100% of Scheme Rate.
Radiology and pathology: 
100% of Scheme Rate.
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
100% of Scheme Rate.
MRI and CT scans: 
Covered at Network Providers. Subject to Scheme Protocols and PMBs. Pre-authorisation required.
ICU and High Care: 
100% of Scheme Rate.
Dialysis: 
Covered at Network Providers. Subject to Scheme Protocols and PMBs. Pre-authorisation required.
Organ Transplants: 
Limited to PMBs at a Provincial Hospital in accordance with Public Sector Protocols, waiting lists and Regulation 8(3) of the Act.
Oncology / Cancer: 
Oncologist, Chemotherapy, Radiotherapy & Oncology-related blood tests. Limited to R80 904 per family per annum. Subject to ICON Network and standard protocols. Pre-authorisation required.
Neck and Back Operations: 
Subject to PMB only.
Joint Replacements: 
Subject to PMB only.
Prosthesis: 

Prosthesis sub-limits.

Overall option limit: R37 685.

Knee: R29 804.

Hip: R29 804.

Shoulder / Elbow / Ankle: R37 685.

External fixator: R37 685.

SPINAL FUSION:

1 Level CERVICAL - R21 026 & LUMBAR DORSAL - R23 706.

2 Level CERVICAL - R32 315 & LUMBAR DORSAL - R37 685.

3 Level CERVICAL - R37 685 & LUMBAR DORSAL - R37 685.

4 Or more Levels CERVICAL - R37 685 & LUMBAR DORSAL - R37 685.

CORONORY STENTS: 1 Stent - R23 706. 2 Stents -R37 685. Total - R37 685.

Pelvic floor - R7 828.

Hernia mesh - R7 828.

Intraocular lens (left) - R2 353. Intraocular lens (right) - R2 353.

Medical and Surgical Appliances: 
External medical appliances, R1973 per family PA, subject to sub-limits: Back supports R1973. CPAP Machine(3y cycle) R1973. Glucometers(3y cycle) R775. Hearing aids(annual, 3y lifespan/appliance) R1973. Nebulisers(3y cycle) R775. Wheelchairs R1973.
Maternity Confinements: 
Normal delivery: 3 days & 2 nights. Caesarean Section (clinically indicated only): 4 days & 3 nights. Elective Caesarean Section: No benefit. Neonatal Intensive Care: Subject to Scheme Protocols.
In Hospital Dentistry: 
Subject to PMBs only. Pre-authorisation required. Multiple hospital admissions are not covered. Scheme Protocols apply.
Take home Medicine: 
Maximum of 7 days’ supply.
Rehabilitation, Hospice and Step-down facilities: 
No benefit.
Treatment for Mental Health: 
Limited to Network Providers and subject to PMBs and Scheme Protocols.
HIV / AIDS: 
Primary care including Voluntary Counselling, Testing & Treatment. Hospitalisation if member is registered on the HIV Management Programme, at Network hospitals. Subject to Scheme Protocols & PMBs. If not registered limited to Provincial Facility.
Ambulance Service: 
Limited to Netcare 911, 100% of Scheme Rate.
International Travel Benefit: 
No benefit.
Day-to-day benefits
GP consultations: 

Unlimited at Foundation Network Providers with authorisation required after 4th visit per beneficiary.

Non-Contracted Providers up to 100% of Scheme Rate (limited to 2 out-of-network visits per family).

Contracted Providers up to 100% of Contracted Rate.

Specialist consultations: 

Subject to Prescribed Minimum Benefits and referral by GP Provider.

Subject to pre-authorisation and limited to Specialist Network Providers.

Acute medicine: 

Limited to Network Providers.

Scheme Protocols and Formularies apply.

For Non-Dispensing Providers, script limit of R99 per event (limited to 4 events per beneficiary).

Over-the-counter (OTC) Medicine: 

No benefit.

Optometry benefits: 
24 month cycle, 1 consultation per beneficiary. Spectacles, Inclusive of a frame and consultation per beneficiary 1 pair of: single vision R1104 or flat top bifocal R1680.
Basic dentistry: 
Subject to Scheme Protocols, Network Providers and sub-limits of: M R1973, M+ R3287. 2 Annual checkups & 2 emergency consults, Oral Xrays Intra: 8 & Extra: 1 per beneficiary. Fillings, Extractions, Emergency Root canal therapy covered.
Specialised Dentistry: 
No benefit.
Orthodontics: 

No benefit.

MRI and CT Scans (Out of Hospital): 
Covered at Network Providers. Subject to Scheme Protocols and PMBs. Pre-authorisation required
Radiology and Pathology: 
Limited to PMBs. Subject to Network Provider Formulary list.
Pregnancy benefits: 
Antenatal care. Maternity programme (registration required). 9 Consultations (GPs or Midwives only. Specialists require authorisation). 2 2D Scans.
Physiotherapy and Occupational Therapy day to day: 
No benefit.
Chronic Conditions
Provider: 
Should be obtained from a Designated Service Provider.
Chronic Conditions: 

25 CDL conditions + HIV, BPH and HRT. • Addison’s Disease • Asthma • Benign Prostatic Hypertrophy • Bipolar Affective Mood Disorders • Bronchiectasis • Cardiac Dysrhythmia (Arrhythmia) • Cardiac Failure • Cardiomyopathy • Chronic Obstructive Pulmonary Disorders (COPD) • Chronic Renal Failure / Disease • Crohn’s Disease • Diabetes Insipidus • Diabetes Mellitus Type 1 & 2 • Epilepsy • Glaucoma • Haemophilia • HIV • Hormone Replacement Therapy • Hyperlipidaemia • Hypertension • Hypothyroidism • Ischaemic Heart Disease (Coronary Artery Disease) • Multiple Sclerosis • Parkinson’s Disease • Rheumatoid Arthritis • Schizophrenia • Systemic Lupus Erythematosis • Ulcerative Colitis ADDITIONAL CHRONIC CONDITIONS: • ADHD • Allergic Rhinitis • Angina Pectoris • Ankylosing Spondylitis • Arthritis • Cerebrovascular Accident (Stroke) • Cushing’s Syndrome • Delusional Disorder • Eczema • Gastro-Oesophageal Reflux Disease (GORD) • Gout • Hyperthyroidism • Idiopathic Thrombocytopenic Purpura • Interstitial Fibrosis of the Lung • Major Depression • Meniere’s Syndrome • Motor Neuron Disease • Myasthenia Gravis • Osteoporosis • Paget’s Disease • Peripheral Vascular Disease • Pituitary Adenoma • Psoriasis • Scleroderma • Urinary Incontinence

Additional Chronic Conditions: 
No benefit.
Preventative Care Benefits
Preventative Benefits: 

Blood pressure, Blood sugar, Cholesterol, Body Mass Index Included in the Foundation Network Providers consultation.

HIV test, 1 Test per beneficiary per annum.

Pap smears, 1 Test per beneficiary per annum .

PSA testing, 1 Test per beneficiary per annum over the age of 45 years.

Vaccinations, Flu, At discretion of Foundation Network Providers. Childhood immunisations at discretion of Foundation Network Providers.

Nurse helpline (including Rape Crises Centre) Advice and information regarding any emergency medical condition. Call 086 111 2162.

Total Contributions
Total Contribution Main Member: 
1151.00
Total Contribution Adult: 
1151.00
Total Contribution Child*: 
397.00
FOUNDATION R4 841 - R7 470
Risk Contributions
Risk Contribution Main Member: 
1151.00
Risk Contribution Adult: 
1151.00
Risk Contribution Child: 
397.00
How many times per annum do you and your dependants visit a doctor?: 
4
How much do you spend on Acute medication per annum?: 
Less than R 1000
How much do you spend on Chronic medication per annum?: 
Less than R 1000
Will you or any of your dependants require specialised Dentistry: 
No
Medical Aid Plan Name Term: 
Any