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Resolution Health HOSPITAL 2018

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Type of Medical Aid Plan: 
Hospital
Medical Aid Year: 
2018
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. Subject to Scheme Protocols and option-specific exclusion list.

Upfront Payments to hospitals: 

R4 110 co-payment applicable for non-DSP hospitals

CO-PAYMENTS

Arthroscopy: R3 957

Circumcision: R2 642

Colonoscopy, sigmoidoscopy, proctoscopy: R2 642

Conservative back / spinal treatment: R3 957

Cystoscopy: R2 642

Dental admissions: R2 642

Excision nailbed: R1 984

Gastroscopy: R2 642

Endometrial ablation: R3 957

Hernia repair: R3 957

Hysterectomy: R3 957

Hysteroscopy: R2 971

Joint replacements: R7 550

Laparoscopic procedures: R3 957

Myringotomy: R2 313

Nasal surgery (including endoscopy): R5 942

Reflux surgery: R11 343

Rotator cuff surgery: R7 550

Skin lesions: R1 984

Spinal surgery: R8 255

Tonsillectomy and adenoidectomy: R2 313

Tympanoplasty: R1 984

Urinary incontinence repair: R3 957

Varicose veins: R3 957

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 100% 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. R2 642 co-payment.
MRI and CT scans: 
CT, MRI, PET and Nuclear Medicine scans, R7915 per family per annum. Subject to Scheme Protocols. Co-payment of R1 996 per incident (in-and-out of hospital). Pre-authorisation required. 100% of Scheme Rate.
ICU and High Care: 
100% of Scheme Rate.
Dialysis: 
Covered at Network Providers. Subject to Scheme Protocols and PMB's. 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 R180 081 per family per annum. Subject to ICON Network and standard protocols. Pre-authorisation required.
Neck and Back Operations: 
Conservative back / spinal treatment. Subject to PMB only. Co-Payment R3 957.
Joint Replacements: 
Subject to PMB only. Co-Payment R7 750.
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, R4122 per family PA, subject to sub-limits: Back supports R4 122. CPAP Machine(3y cycle) R4 122. Glucometers(3y cycle) R775. Hearing aids(, annual3y lifespan/appliance) R4 122. Nebulisers(3y cycle) R775. Wheelchairs R4 122.
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: 
Limited to R4616 per family per annum for impacted wisdom teeth and associated costs. Multiple hospital admissions are not covered. Co-payment of R2643 will apply to all inhospital dental admissions. Scheme Protocols apply.
Take home Medicine: 
Maximum of 7 days’ supply.
Rehabilitation, Hospice and Step-down facilities: 
10 Days per family per annum. 100% of Scheme Rate.
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: 
Limited to emergency medical cover up to R750 000 per beneficiary per incident.
Day-to-day benefits
GP consultations: 

2 Visits per family per annum, R150 co-payment per visit.

Non-Contracted Providers up to 100% of Scheme Rate.

Contracted Providers up to 100% of Contracted Rate.

Specialist consultations: 

Limited to Prescribed Minimum Benefits at Network Providers.

Subject to pre-authorisation.

Acute medicine: 

No benefit.

Over-the-counter (OTC) Medicine: 

No benefit.

Optometry benefits: 
No benefit.
Basic dentistry: 
No benefit.
Specialised Dentistry: 
No benefit.
Orthodontics: 

No benefit.

MRI and CT Scans (Out of Hospital): 
CT, MRI, PET and Nuclear Medicine scans, R7915 per family per annum. Subject to Scheme Protocols. Co-payment of R1 996 per incident (in-and-out of hospital). Pre-authorisation required. 100% of Scheme Rate.
Radiology and Pathology: 
Limited to PMBs.
Pregnancy benefits: 
Antenatal care. Maternity programme (registration required). 9 Consultations (Midwife, GP or Specialist), Subject to Scheme Protocols and PMBs. 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: 
No benefit.
Preventative Care Benefits
Preventative Benefits: 

Preventative care limit: R2 493 per family per annum. Scheme Rate applies.

Pap smears, 1 Test per beneficiary per annum over the age of 45 years.

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

Vaccinations, Flu, 1 Dose flu vaccination per beneficiary per annum. R1 875 benefit for childhood immunisations as recommended by the Department of Health up to 18 months.

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

Oral contraception R1 000 per female beneficiary per annum (R83 per month).

Total Contributions
Total Contribution Main Member: 
1720.00
Total Contribution Adult: 
1450.00
Total Contribution Child*: 
640.00
HOSPITAL
Risk Contributions
Risk Contribution Main Member: 
1720.00
Risk Contribution Adult: 
1450.00
Risk Contribution Child: 
640.00
How many times per annum do you and your dependants visit a doctor?: 
2
How much do you spend on Acute medication per annum?: 
0
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