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Rise 2021

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

No Benefit. Subject to PMB’s

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 at 100% of SR. Physiotherapy at 100% of SR limited to R2 641 if non-PMB
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 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: 
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: 

Subject to Scheme Protocols and PMB's

Medical and Surgical Appliances: 
PMB's only
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: 
Limited to R3 500 for impacted wisdom teeth, includes hospital and anaesthetist. No cover for dental surgeon. 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: 

No benefit

Specialist consultations: 

No benefit

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): 
No benefit
Radiology and Pathology: 
No benefit
Pregnancy benefits: 
Subject to registration on the Maternity Programme. 2 GP or gynaecologist consultations, 2x 2D scans and R559 available for antenatal classes
Physiotherapy and Occupational Therapy day to day: 
No benefit
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: 

Pap smear and PSA screening for beneficiaries older than 45 years, HIV test; flu vaccine and childhood immunisations as recommended by the Department of Health, up to 18 months and subject to a limit of R2 097, oral contraceptives limit of R1 116 per female beneficiary per annum, with a sub-limit of R93 per month

Total Contributions
Total Contribution Main Member: 
1668.00
Total Contribution Adult: 
1509.00
Total Contribution Child*: 
570.00
Rise
Medical Aid Plan Name Term: 
Rise