SUMMARY – 2018/2019

 

Can I have a quick overview of the Plans?

The Fund continues to offer as much choice to its members as feasible, with a total of eight Plans to choose from in the 2018/19 benefit year.

The Plans range from lower cost options that offer lower cover, to higher cost options that offer more comprehensive cover.

In addition, members can also choose one of the SELECT  Plans, which offer a reduced contribution rate in return for access to selected hospitals only.

The Plans differ quite extensively, both in terms of benefits in hospital and out of hospital, as can be seen from the graphic below. Please refer to the summary tables further down, as well as the detailed tables in your Member Guide, for more information.

The Fund’s benefit year runs from 1 July to 30 June of the following year. You will be entitled to full benefits if your membership is active at the beginning of the benefit year. If you join the Fund during a benefit year, you will only be entitled to pro-rata benefits. If there is movement in membership, for example, the addition or removal of a dependant, benefits will be adjusted accordingly.

Overview of Plans

Universal Healthcare

OMSMAF has appointed Universal Healthcare (Pty) Ltd to replace CareCross as our Network provider on the Network and Network SELECT  Plans, with effect from 1 July 2018. This change does not affect your benefits.


  Hospital Plan Network / Network SELECT  Plan* Savings Plan Traditional / Traditional SELECT  Plan* Traditional Plus / Traditional Plus SELECT  Plan*
DAY-TO-DAY
BENEFITS
Limited Primary Care Benefits for specified procedures only
 
No Personal Medical Savings Account
NEW! Primary healthcare benefits via Universal Healthcare Network GPs
 
No Personal Medical Savings Account
Limited to Personal Medical Savings Account only; no PCB limits Comprehensive; from Personal Medical Savings Account at cost; then from PCB at 1 x MSR Very comprehensive; from Personal Medical Savings Account at cost; then from PCB at 3 x MSR
SUPPLEMENTARY
BENEFITS
Limited, paid at 1 x MSR Limited, paid at 1 x MSR Limited, paid at 1 x MSR Comprehensive, paid at 1 x MSR Comprehensive, paid at 1 x MSR
WELLNESS
BENEFITS
Standard Standard Standard Standard Standard
CHRONIC
BENEFITS
Limited NEW! Via Universal Healthcare Network GPs Limited Comprehensive Comprehensive
HOSPITAL
BENEFITS
Limited to R1m per beneficiary per benefit year. Certain elective procedures, including hip, knee, shoulder and elbow replacements, are not covered, other than in accordance with Prescribed Minimum Benefits. Refer to detailed table under Hospital Benefits.
 
Oncology covered within ICON Essential Protocols
Unlimited overall annual limit (subject to certain sub-limits), but more limited than higher-cost Plans. Certain elective procedures, including hip, knee, shoulder and elbow replacements, are not covered, other than in accordance with Prescribed Minimum Benefits. See page 83 in your Member Guide for more information.
 
Oncology covered within ICON Essential Protocols
*Please note that under the SELECT  Plan, members’ choice of hospitals is restricted – see page 20 in your Member Guide for more information.
Unlimited overall annual limit (subject to certain sub-limits)
 
Oncology covered within ICON Enhanced Protocols
Comprehensive, with unlimited overall annual limit (subject to certain sub-limits)
 
Oncology covered within ICON Enhanced Protocols (higher benefit sub-limit)
*Please note that under the SELECT  Plan, members’ choice of hospitals is restricted – see page 20 in your Member Guide for more information.
Comprehensive, with unlimited overall annual limit (subject to certain sub-limits)
 
Oncology covered within ICON Enhanced Protocols (higher benefit sub-limit)
*Please note that under the SELECT  Plan, members’ choice of hospitals is restricted – see page 20 in your Member Guide for more information.

 


The tables below highlight the differences between the Plans in more detail.

Out-of-hospital: DAY-TO-DAY BENEFITS

THE FOLLOWING IS A SUMMARY ONLY – PLEASE SEE PAGES 38-52 IN YOUR MEMBER GUIDE FOR MORE INFORMATION.

  Hospital Plan Network / Network SELECT  Plan Savings Plan Traditional / Traditional SELECT  Plan Traditional Plus / Traditional Plus SELECT  Plan
Rate payable Paid at 1 x Medical Scheme Rates (MSR) Paid up to 3 x MSR
Personal Medical Savings Account
(PMSA) – see page 109 in your Member Guide.
No No Yes Yes Yes
Primary Care Benefit (PCB) Limit R1 860 per family for specified procedures in doctors’ rooms only. NEW! At Universal Healthcare Network Provider No PCB benefit; benefits are payable from available PMSA or, thereafter, accumulated savings. Depends on income band and family size – see page 48 in your Member Guide. Depends on income band and family size – see page 48 in your Member Guide.
GPs and Specialists No benefit. NEW! Medically necessary visits to Universal Healthcare Network GPs, subject to Universal Healthcare benefits. No specialist benefits. At 100% of cost from PMSA and then from accumulated savings, subject to available funds. At 100% of cost from PMSA, then at 1 x MSR from PCB, up to overall Day-to-Day limit.
Thereafter, accumulated savings can be used.
At 100% of cost from PMSA, then at 3 x MSR from PCB, up to overall Day-to-Day limit.
Thereafter, accumulated savings can be used.
Specified procedures in doctors’ rooms Subject to PCB limit. NEW! Covers minor trauma treatment and small procedures in Universal Healthcare Network GPs’ rooms. At 100% of cost from PMSA and then from accumulated savings, subject to available funds. At 100% of cost from PMSA, then at 1 x MSR from PCB, up to overall Day-to- Day limit.
Thereafter, accumulated savings can be used.
At 100% of cost from PMSA, then at 3 x MSR from PCB, up to overall Day-to- Day limit.
Thereafter, accumulated savings can be used.
Dentistry No benefit. NEW! Covers fillings, primary extractions, scaling and polishing at Universal Healthcare network provider. At 100% of cost from PMSA and then from accumulated savings, subject to available funds. At 100% of cost from PMSA, then at 1 x MSR from PCB, up to overall Day-to-Day limit.
Thereafter, accumulated savings can be used.
At 100% of cost from PMSA, then at 3 x MSR from PCB, up to overall Day-to-Day limit.
Thereafter, accumulated savings can be used.
Radiology No benefit. NEW! Basic X-rays as requested by Universal Healthcare Network GP and subject to Universal Healthcare protocols. At 100% of cost from PMSA and then from accumulated savings, subject to available funds. At 100% of cost from PMSA, then at 1 x MSR from PCB, up to overall Day-to- Day limit.
Thereafter, accumulated savings can be used.
At 100% of cost from PMSA, then at 3 x MSR from PCB, up to overall Day-to- Day limit.
Thereafter, accumulated savings can be used.
Pathology No benefit. NEW! Basic blood tests as requested by Universal Healthcare Network GP and subject to Universal Healthcare protocols. At 100% of cost from PMSA and then from accumulated savings, subject to available funds. At 100% of cost from PMSA, then at 1 x MSR from PCB, up to overall Day-to- Day limit.
Thereafter, accumulated savings can be used.
At 100% of cost from PMSA, then at 3 x MSR from PCB, up to overall Day-to- Day limit.
Thereafter, accumulated savings can be used.
Psychology No benefit. No benefit. At 100% of cost from PMSA and then from accumulated savings, subject to available funds. At 100% of cost from PMSA, then at 1 x MSR from PCB, up to overall Day-to- Day limit.
Thereafter, accumulated savings can be used.
At 100% of cost from PMSA, then at 3 x MSR from PCB, up to overall Day-to- Day limit.
Thereafter, accumulated savings can be used.
Prescribed (acute) medicines No benefit. NEW! Acute medicines on the Universal Healthcare Network Acute Medicine Formulary as prescribed by Universal Healthcare Network GP and dispensed by Universal Healthcare Network Dispensing GP or Universal Healthcare Network Pharmacy. At 100% of MPL or medicine price, whichever is the lesser, from PMSA and then from accumulated savings, subject to available funds. At 100% of MPL or medicine price, whichever is the lesser, from PMSA. Once PMSA is depleted, from PCB at 100% of MPL or medicine price, whichever is the lesser.

Thereafter, accumulated savings can be used.

At 100% of MPL or medicine price, whichever is the lesser, from PMSA. Once PMSA is depleted, from PCB at 100% of MPL or medicine price, whichever is the lesser.

Thereafter, accumulated savings can be used.

Pharmacy-Advised Therapy (PAT) No benefit. No benefit. At 100% of MPL or medicine price, whichever is the lesser, from PMSA and then from accumulated savings, subject to available funds.

(Medicine exclusion list may apply.)

At 100% of MPL or medicine price, whichever is the lesser, from PMSA. Once PMSA is depleted, from PCB at 100% of MPL or medicine price, whichever is the lesser.

(Medicine exclusion list may apply.)

Thereafter, accumulated savings can be used.

At 100% of MPL or medicine price, whichever is the lesser, from PMSA. Once PMSA is depleted, from PCB at 100% of MPL or medicine price, whichever is the lesser.

(Medicine exclusion list may apply.)

Thereafter, accumulated savings can be used.

Auxiliary Services No benefit. No benefit. At 100% of cost from PMSA and then from accumulated savings, subject to available funds. At 100% of cost from PMSA, then at 1 x MSR from PCB, up to overall Day-to-Day limit.

Thereafter, accumulated savings can be used.

At 100% of cost from PMSA, then at 3 x MSR from PCB, up to overall Day-to-Day limit.

Thereafter, accumulated savings can be used.

Physiotherapy No benefit. No benefit. At 100% of cost from PMSA and then from accumulated savings, subject to available funds. At 100% of cost from PMSA, then at 1 x MSR from PCB, up to overall Day-to-Day limit.

Thereafter, accumulated savings can be used.

At 100% of cost from PMSA, then at 3 x MSR from PCB, up to overall Day-to-Day limit.

Thereafter, accumulated savings can be used.

Optical benefits

  • Eye tests

  • Spectacles, Frames, Contact Lenses and Readers (including fitting consultation for contact lenses)

No benefit. NEW! Subject to Universal Healthcare Optometry Network protocols and to be obtained from Universal Healthcare Optometry Network providers. At 100% of cost from PMSA and then from accumulated savings, subject to available funds. At 100% of cost from PMSA, then at 1 x MSR from PCB, up to overall Day-to-Day limit.

Thereafter, accumulated savings can be used.

At 100% of cost from PMSA, then at 3 x MSR from PCB, up to overall Day-to-Day limit.

Thereafter, accumulated savings can be used.

 

Out-of-hospital: SUPPLEMENTARY BENEFITS

THE FOLLOWING IS A SUMMARY ONLY – PLEASE SEE PAGES 53-57 IN YOUR MEMBER GUIDE FOR MORE INFORMATION.

  Hospital Plan Network / Network SELECT  Plan Savings Plan Traditional / Traditional SELECT  Plan Traditional Plus / Traditional Plus SELECT  Plan
Maternity benefits (dependent on registration on the Mother and Baby Care Programme). Members expecting a baby and considering a SELECT  Plan must please make sure that their specialist is at one of the SELECT  list of hospitals.
Antenatal classes No benefit. No benefit. R1 220 per family per benefit year. R1 910 per family per benefit year. R1 910 per family per benefit year.
Antenatal visits No benefit. NEW! Please refer to Network / Network SELECT  Plan section for services rendered by Universal Healthcare. R2 870 per pregnancy. R4 780 per pregnancy. R4 780 per pregnancy.
Ultrasound scans (pregnancy) No benefit. NEW! Two 2D scans per pregnancy at Universal Healthcare Network GP, or referral by Universal Healthcare Network GP to a radiologist. Two 2D scans per beneficiary. Two 2D scans per beneficiary. Two 2D scans per beneficiary.
Out-of-hospital pathology tests No benefit. NEW! Please refer to Network / Network SELECT  Plan section for services rendered by Universal Healthcare. R2 360 per family per benefit year. R2 950 per family per benefit year. R2 950 per family per benefit year.
Antenatal vitamins No benefit. No benefit. 100% of MPL or Medicine Price, subject to prescription and included in the Hospital Benefit. 100% of MPL or Medicine Price, subject to prescription and included in the Hospital Benefit. 100% of MPL or Medicine Price, subject to prescription and included in the Hospital Benefit.
Ultrasound scans in and out of hospital (other than for pregnancy) – combined benefit limit

The co-payment will not be applicable to pregnancy related scans, oncology related scans, organ transplant related scans and the first mammogram.

R4 550 per family per benefit year, with a co-payment of R500 per beneficiary per day, for non-PMB Ultrasound scans rendered in and out of hospital. R4 550 per family per benefit year, with a co-payment of R500 per beneficiary per day, for non-PMB Ultrasound scans rendered in and out of hospital. R4 550 per family per benefit year, with a co-payment of R500 per beneficiary per day, for non-PMB Ultrasound scans rendered in and out of hospital. R6 780 per family per benefit year, with a co-payment of R500 per beneficiary per day, for non-PMB Ultrasound scans rendered in and out of hospital. R6 780 per family per benefit year, with a co-payment of R500 per beneficiary per day, for non-PMB Ultrasound scans rendered in and out of hospital.
Specialised Radiology in and out of hospital (including MRI, CT and Radio-isotope Scans and Nuclear Medicine) – combined benefit limit R13 400 per family per benefit year, with a co-payment of R1 500 per authorisation.

R13 400 per family per benefit year, with a co-payment of R1 500 per authorisation. R13 400 per family per benefit year, with a co-payment of R1 500 per authorisation. R16 500 per family per benefit year, with a co-payment of R1 500 per authorisation. R16 500 per family per benefit year, with a co-payment of R1 500 per authorisation.
Dental implants No benefit, except for Prescribed Minimum Benefits. No benefit, except for Prescribed Minimum Benefits. At 100% of cost from PMSA and then from accumulated savings, subject to available funds. R13 800 per family per benefit year. R13 800 per family per benefit year.
Medical Appliances No benefit, except for Prescribed Minimum Benefits. No benefit, except for Prescribed Minimum Benefits. At 100% of cost from PMSA and then from accumulated savings, subject to available funds. R9 170 per family per benefit year, subject to approval and a co-payment of 10% per appliance for non-PMBs. R9 170 per family per benefit year, subject to approval and a co-payment of 10% per appliance for non-PMBs.
Foot Orthotics No benefit, except for Prescribed Minimum Benefits. No benefit, except for Prescribed Minimum Benefits. At 100% of cost from PMSA and then from accumulated savings, subject to available funds. R4 140 per family and included in the appliance limit of R9 170 per family above, subject to a co-payment of 10% per appliance for non-PMBs. R4 140 per family and included in the appliance limit of R9 170 per family above, subject to a co-payment of 10% per appliance for non-PMBs.
Hearing Aids
(including repairs – see page 57 in your Member Guide)
No benefit, except for Prescribed Minimum Benefits. No benefit, except for Prescribed Minimum Benefits. At 100% of cost from PMSA and then from accumulated savings, subject to available funds. R16 300 per ear per beneficiary, subject to a co-payment of 10%. Benefit is available every 3 years for beneficiaries under age 7, and every 5 years for beneficiaries older than 7 years. The benefit excludes consultations and associated tests. R16 300 per ear per beneficiary, subject to a co-payment of 10%. Benefit is available every 3 years for beneficiaries under age 7, and every 5 years for beneficiaries older than 7 years. The benefit excludes consultations and associated tests.
Refractive procedures No benefit, except for Prescribed Minimum Benefits. No benefit, except for Prescribed Minimum Benefits. At 100% of cost from PMSA and then from accumulated savings, subject to available funds. 1 x MSR or cost, whichever is the lesser, up to a sub-limit of R14 500 per beneficiary per benefit year. See page 57 in your Member Guide for more information. 1 x MSR or cost, whichever is the lesser, up to a sub-limit of R14 500 per beneficiary per benefit year. See page 57 in your Member Guide for more information.
Back and Neck Rehabilitation Programme See page 90 in your Member Guide for more information.
Mental Health Programme R10 000 per beneficiary per benefit year. See page 97 in your Member Guide for more information.

 

Out-of-hospital: WELLNESS BENEFITS

THE FOLLOWING IS A SUMMARY ONLY – PLEASE SEE PAGES 58-60 IN YOUR MEMBER GUIDE FOR MORE INFORMATION.

  Hospital Plan Network / Network SELECT  Plan Savings Plan Traditional / Traditional SELECT  Plan Traditional Plus / Traditional Plus SELECT  Plan
Wellness Benefit

(1 per beneficiary per benefit year)

  • Pharmacy-based health-screening tests: Blood pressure, blood glucose, cholesterol, HIV/AIDS, BMI. One of each screening test per beneficiary per benefit year.
  • Pharmacy-based vaccines: One flu vaccine per beneficiary per benefit year; one pneumococcal vaccine per lifetime.
  • Contraceptive benefit: R2 840 per beneficiary per benefit year. R1 790 sublimit for oral contraceptives.
  • Non-pharmacy based benefits consist of one pap smear and mammogram per female beneficiary per benefit year and one prostate test per male beneficiary, as well as colorectal screening, limited to one test per beneficiary per benefit year, including the consultation at the GP or gynaecologist (for female beneficiaries) or urologist (for male beneficiaries), paid up to the Medical Scheme Rates for a visit to a GP, gynaecologist or urologist, plus one health risk assessment per beneficiary per benefit year for services rendered by a registered healthcare practitioner (such as a General Practitioner). It is very important that your service provider uses the correct ICD-10 code to claim for these benefits – see the green note on page 60 in your Member Guide for more information.
  • Hearing screening for newborns up to six weeks.
  • NEW! PAED-IQ’s Babyline -A 24/7, paediatric Telephone service, whereby parents or caregivers of children from birth to three years of age can phone in and get up-to-date child healthcare advice and reassurance.
    Call 0860 666 110

 

Out-of-hospital: CHRONIC BENEFITS

THE FOLLOWING IS A SUMMARY ONLY – PLEASE SEE PAGES 61-70 IN YOUR MEMBER GUIDE FOR MORE INFORMATION.

  Hospital Plan Network / Network SELECT  Plan Savings Plan Traditional / Traditional SELECT  Plan Traditional Plus / Traditional Plus SELECT  Plan
Non-PMB conditions A limit of R4 780 per family (for Chronic Hepatitis, Depression, Macular Degeneration and Oedema, Anxiety and Post-Traumatic Stress Disorder only) subject to Medicine Price List (MPL) or the Medicine Price. Subject to the Universal Healthcare Medicine Benefit, Chronic Disease List Formulary and approval. In addition, a benefit for Chronic Hepatitis, Macular Degeneration and Oedema, Anxiety and Post Traumatic Stress Disorder. Preauthorised by Universal Healthcare Chronic Medicine Management. A limit of R4 780 per family (for Chronic Hepatitis, Depression, Macular Degeneration and Oedema, Anxiety and Post-Traumatic Stress Disorder only), subject to Medicine Price List (MPL) or the Medicine Price. For other conditions, subject to available PMSA or, thereafter, accumulated savings. A limit of R11 600 per family per benefit year, subject to chronic medicine benefit and Chronic Disease Lists and approval. A limit of R13 900 per family per benefit year, subject to chronic medicine benefit and Chronic Disease Lists and approval.
PMB Conditions Unlimited subject to the OMSMAF restrictive formulary. Unlimited subject to Universal Healthcare Formulary and approval. Preauthorised by Universal Healthcare Chronic Medicine Management. Unlimited subject to the OMSMAF restrictive formulary. Unlimited subject to the OMSMAF comprehensive formulary. Unlimited subject to the OMSMAF comprehensive formulary.

 

In-hospital: HOSPITAL BENEFITS (HB)

THE FOLLOWING IS A SUMMARY ONLY – PLEASE SEE PAGES 71-89 IN YOUR MEMBER GUIDE FOR MORE INFORMATION.

  Hospital Plan Network / Network SELECT  Plan Savings Plan Traditional / Traditional SELECT  Plan Traditional Plus / Traditional Plus SELECT  Plan
Hospital Benefits Annual limit of R1 000 000 per beneficiary per benefit year for HB, subject to certain sub-limits. Unlimited PMB if obtained from a DSP. Unlimited cover for Hospital Benefits (HB), subject to certain sub-limits.

Unlimited Prescribed Minimum Benefits (PMB) if obtained from a Designated Service Provider (DSP).

NOTE: Under the Hospital, Network and Network SELECT  Plans, certain elective procedures including hip, knee, shoulder and elbow replacements, are not covered, other than in accordance with Prescribed Minimum Benefits. See page 83 in your Member Guide for more information.

 

Terms used in the table:

  • DSP – a healthcare provider selected and formally contracted by the Fund as its preferred service provider to provide diagnosis, treatment and care in respect of one or more conditions.
  • Medicine Price List (MPL) – a reference pricing system that uses a benchmark or reference price for generically similar products.
  • Medicine Exclusion List (MEL) – exclusion list used by the Fund, which excludes medicines from payment from the Acute Medicine Benefit for a number of reasons.
  • OMSMAF Restrictive Medicine Formulary – Applicable to the Hospital and Savings Plans. Contains a list of medicines that provide cover for the listed chronic conditions.
  • OMSMAF Comprehensive Medicine Formulary – Applicable to the Traditional and Traditional Plus (including SELECT ) Plans. It provides access to a wider range of medicines than the restrictive formulary.

What do I need to know about the SELECT  Plans?

Why have the SELECT  Plans been introduced?

Healthcare costs rise at a faster rate than inflation each year and impact member contributions. The Fund is therefore always exploring ways to contain costs without compromising quality.

One such measure is the Network SELECT , Traditional SELECT  and Traditional Plus SELECT  Plans, where the Fund negotiated discounted rates with certain hospitals.

The SELECT  Plans are based on offering the same benefits as those on the standard Plans, but at a reduced contribution – in return for members then using the SELECT  list of hospitals (see the online look-up tool).

For example:

A Traditional Plan member moving to the Traditional SELECT  Plan –

  • pays a reduced contribution; and
  • retains the same benefits;

– by using one of our SELECT  list of hospitals.

How were the hospitals for SELECT  Plans chosen?

Apart from the level of discount being offered, the Fund more importantly considered the quality and accessibility of care to most members.

Are there any differences in the benefits between the standard and SELECT  Plans?

The benefits are the same. The only small difference in benefits between the standard and SELECT  Plans can be seen in the Day-to-Day Benefits on the Traditional and Traditional Plus Plans and their SELECT  counterparts. As the SELECT  Plans have lower contributions, this will slightly reduce the amount members on these Plans pay towards their Personal Medical Savings Account (PMSA), since both Plans contribute the same percentage of contributions.

What if I choose a SELECT  Plan and then visit a hospital not on the SELECT  list of hospitals?

Unless it is a legitimate emergency (see ‘What if there is an emergency?’ below), members on SELECT  who use a hospital that is not on the SELECT  list will incur a co-payment of 20% of the total hospital bill.
This co-payment will be payable to the hospital and might be charged upfront or at the time of discharge.

What if my specialist is not at one of the SELECT  list of hospitals?

If your specialist does not practise at one of the listed hospitals, you should probably not consider choosing a SELECT  Plan, unless you are willing to move to a specialist who is based at one of the SELECT  list of hospitals. You can check this with your doctor.

What if there is an emergency?

An emergency medical condition is defined as “the sudden and, at the time, unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy.”
If you experience such an emergency, you will not incur a 20% co-payment for being on a SELECT  Plan and using a hospital that is not on the SELECT  list of hospitals.

What are the monthly contributions for 2018/19?

Use our handy Contribution Calculator to calculate your family’s monthly contributions for 2018/19.

The total monthly contribution to the Fund is based on the Plan you have chosen, the number of your dependants and your income (see tables below). You can find a definition of income on page 138 in your Member Guide.

The compulsory Personal Medical Savings Account (PMSA) contributions on the Savings, Traditional and Traditional Plus (including SELECT ) Plans are included in the amounts below. (The Hospital, Network and Network SELECT  Plans have no savings portion.)

Please note that contributions are charged in respect of the first three child dependants only.

Any subsidies paid to non-TGP members and qualifying pensioners are included in the monthly contributions. Where the subsidy is higher than the contribution on the Plan you have chosen, you will not be required to make monthly contributions to the Fund.

Late joiner penalties will be imposed in accordance with the Rules of the Fund (please see page 121 in your Member Guide for more information).

Pensioners

Employees who joined Old Mutual on or before 31 July 1998 and who were members of the Fund on 1 June 2007, and continue as members of the Fund after retirement, qualify to receive a subsidy from Old Mutual during retirement. However, employees who joined Old Mutual from 1 August 1998 do not qualify to receive a subsidy from Old Mutual during retirement. They will therefore be responsible for the full monthly contribution to the Fund after retirement.

Hospital Plan
Income band Contribution Member Adult Child (max 3)
R0 – R4 730 RISK R798 R623 R174
PMSA R0 R0 R0
TOTAL R798 R623 R174
R4 731R7 100 RISK R862 R672 R179
PMSA R0 R0 R0
TOTAL R862 R672 R179
R7 101R9 470 RISK R1 021 R802 R201
PMSA R0 R0 R0
TOTAL R1 021 R802 R201
R9 471R12 650 RISK R1 375 R1 106 R355
PMSA R0 R0 R0
TOTAL R1 375 R1 106 R355
R12 651R18 750 RISK R1 531 R1 231 R396
PMSA R0 R0 R0
TOTAL R1 531 R1 231 R396
R18 751R31 270 RISK R1 610 R1 293 R416
PMSA R0 R0 R0
TOTAL R1 610 R1 293 R416
R31 271+ RISK R1 625 R1 304 R419
PMSA R0 R0 R0
TOTAL R1 625 R1 304 R419

 

Network Plan
Income band Contribution Member Adult Child (max 3)
R0 – R4 730 RISK R1 389 R1 154 R437
PMSA R0 R0 R0
TOTAL R1 389 R1 154 R437
R4 731R7 100 RISK R1 817 R1 164 R462
PMSA R0 R0 R0
TOTAL R1 817 R1 164 R462
R7 101R9 470 RISK R1 883 R1 204 R479
PMSA R0 R0 R0
TOTAL R1 883 R1 204 R479
R9 471R12 650 RISK R2 058 R1 730 R718
PMSA R0 R0 R0
TOTAL R2 058 R1 730 R718
R12 651R18 750 RISK R2 130 R1 789 R743
PMSA R0 R0 R0
TOTAL R2 130 R1 789 R743
R18 751R31 270 RISK R2 152 R1 809 R752
PMSA R0 R0 R0
TOTAL R2 152 R1 809 R752
R31 271+ RISK R2 171 R1 827 R760
PMSA R0 R0 R0
TOTAL R2 171 R1 827 R760

 

Network SELECT  Plan
Income band Contribution Member Adult Child (max 3)
R0 – R4 730 RISK R1 252 R1 040 R394
PMSA R0 R0 R0
TOTAL R1 252 R1 040 R394
R4 731R7 100 RISK R1 638 R1 049 R417
PMSA R0 R0 R0
TOTAL R1 638 R1 049 R417
R7 101R9 470 RISK R1 698 R1 086 R431
PMSA R0 R0 R0
TOTAL R1 698 R1 086 R431
R9 471R12 650 RISK R1 856 R1 560 R647
PMSA R0 R0 R0
TOTAL R1 856 R1 560 R647
R12 651R18 750 RISK R1 920 R1 614 R671
PMSA R0 R0 R0
TOTAL R1 920 R1 614 R671
R18 751R31 270 RISK R1 940 R1 631 R678
PMSA R0 R0 R0
TOTAL R1 940 R1 631 R678
R31 271+ RISK R1 958 R1 647 R685
PMSA R0 R0 R0
TOTAL R1 958 R1 647 R685

 

Savings Plan
Income band Contribution Member Adult Child (max 3)
R0 – R4 730 RISK R1 238 R1 040 R208
PMSA R257 R216 R43
TOTAL R1 495 R1 256 R251
R4 731R7 100 RISK R1 594 R1 058 R260
PMSA R332 R219 R54
TOTAL R1 926 R1 277 R314
R7 101R9 470 RISK R1 655 R1 096 R269
PMSA R343 R228 R56
TOTAL R1 998 R1 324 R325
R9 471R12 650 RISK R1 790 R1 519 R473
PMSA R372 R316 R98
TOTAL R2 162 R1 835 R571
R12 651+ RISK R1 876 R1 593 R496
PMSA R390 R331 R103
TOTAL R2 266 R1 924 R599

 

Traditional Plan
Income band Contribution Member Adult Child (max 3)
R0 – R4 730 RISK R2 094 R1 591 R509
PMSA R270 R205 R65
TOTAL R2 364 R1 796 R574
R4 731R7 100 RISK R2 523 R1 674 R569
PMSA R326 R216 R74
TOTAL R2 849 R1 890 R643
R7 101R9 470 RISK R2 656 R1 764 R600
PMSA R342 R228 R77
TOTAL R2 998 R1 992 R677
R9 471+ RISK R3 087 R2 544 R960
PMSA R399 R329 R124
TOTAL R3 486 R2 873 R1 084

 

Traditional SELECT  Plan
Income band Contribution Member Adult Child (max 3)
R0 – R4 730 RISK R1 889 R1 435 R458
PMSA R243 R185 R59
TOTAL R2 132 R1 620 R517
R4 731R7 100 RISK R2 274 R1 509 R512
PMSA R294 R195 R67
TOTAL R2 568 R1 704 R579
R7 101R9 470 RISK R2 396 R1 590 R542
PMSA R308 R206 R69
TOTAL R2 704 R1 796 R611
R9 471+ RISK R2 783 R2 294 R865
PMSA R360 R297 R112
TOTAL R3 143 R2 591 R977

 

Traditional Plus Plan
Income band Contribution Member Adult Child (max 3)
R0 – R7 100 RISK R4 412 R3 615 R1 372
PMSA R508 R417 R158
TOTAL R4 920 R4 032 R1 530
R7 101+ RISK R5 098 R4 179 R1 585
PMSA R588 R482 R183
TOTAL R5 686 R4 661 R1 768

 

Traditional Plus SELECT  Plan
Income band Contribution Member Adult Child (max 3)
R0 – R7 100 RISK R3 907 R3 202 R1 215
PMSA R450 R369 R140
TOTAL R4 357 R3 571 R1 355
R7 101+ RISK R4 515 R3 702 R1 403
PMSA R521 R427 R162
TOTAL R5 036 R4 129 R1 565

 

What is the annual healthcare spend available for day-to-day medical expenses?

Use our handy Contribution Calculator to calculate your family’s annual healthcare spend available for day-to-day medical expenses.

 

Hospital Plan
Maximum annual PCB limit of R1 860 per family for specified procedures.

 

Network and Network SELECT  Plans
Subject to Universal Healthcare Network benefits.

 

Savings Plan
Income band Member Adult Child (max 3)
R0 – R4 730 Annual PMSA R3 084 R2 592 R516
R4 731R7 100 R3 984 R2 628 R648
R7 101R9 470 R4 116 R2 736 R672
R9 471R12 650 R4 464 R3 792 R1 176
R12 651+ R4 680 R3 972 R1 236

 

Traditional Plan
Income band Member Adult Child (max 3)
R0 – R4 730 Annual PMSA R3 240 R2 460 R780
Annual PCB limit R4 040 R3 430 R1 220
Overall Day-to-Day limit R7 280 R5 890 R2 000
R4 731R7 100 Annual PMSA R3 912 R2 592 R888
Annual PCB limit R4 040 R3 430 R1 220
Overall Day-to-Day limit R7 952 R6 022 R2 108
R7 101R9 470 Annual PMSA R4 104 R2 736 R924
Annual PCB limit R4 040 R3 430 R1 220
Overall Day-to-Day limit R8 144 R6 166 R2 144
R9 471+ Annual PMSA R4 788 R3 948 R1 488
Annual PCB limit R4 040 R3 430 R1 220
Overall Day-to-Day limit R8 828 R7 378 R2 708

 

Traditional SELECT  Plan
Income band Member Adult Child (max 3)
R0 – R4 730 Annual PMSA R2 916 R2 220 R708
Annual PCB limit R4 040 R3 430 R1 220
Overall Day-to-Day limit R6 956 R5 650 R1 928
R4 731R7 100 Annual PMSA R3 528 R2 340 R804
Annual PCB limit R4 040 R3 430 R1 220
Overall Day-to-Day limit R7 568 R5 770 R2 024
R7 101R9 470 Annual PMSA R3 696 R2 472 R828
Annual PCB limit R4 040 R3 430 R1 220
Overall Day-to-Day limit R7 736 R5 902 R2 048
R9 471+ Annual PMSA R4 320 R3 564 R1 344
Annual PCB limit R4 040 R3 430 R1 220
Overall Day-to-Day limit R8 360 R6 994 R2 564

 

As the SELECT  Plans have lower contributions, this will reduce the amount you pay towards your Personal Medical Savings Account (shown as Annual PMSA above).

 

Traditional Plus Plan
Income band Member Adult Child (max 3)
R0 – R7 100 Annual PMSA R6 096 R5 004 R1 896
Annual PCB limit R8 070 R6 460 R2 030
Overall Day-to-Day limit R14 166 R11 464 R3 926
R7 101+ Annual PMSA R7 056 R5 784 R2 196
Annual PCB limit R8 070 R6 460 R2 030
Overall Day-to-Day limit R15 126 R12 244 R4 226

 

Traditional Plus SELECT  Plan
Income band Member Adult Child (max 3)
R0 – R7 100 Annual PMSA R5 400 R4 428 R1 680
Annual PCB limit R8 070 R6 460 R2 030
Overall Day-to-Day limit R13 470 R10 888 R3 710
R7 101+ Annual PMSA R6 252 R5 124 R1 944
Annual PCB limit R8 070 R6 460 R2 030
Overall Day-to-Day limit R14 322 R11 584 R3 974

 

As the SELECT  Plans have lower contributions, this will reduce the amount you pay towards your Personal Medical Savings Account (shown as Annual PMSA above).

 

What must I consider before making a choice?

Before you select your Plan for the coming benefit year, take the following factors into consideration:

  • The monthly contributions of each Plan to ensure that you can afford the Plan you select.
  • Whether the Plan you are considering offers adequate benefits most suited to your medical needs.
  • Your health history or what your medical expenses were during the previous benefit year.
  • Your anticipated healthcare needs during the coming year.
  • The number of dependants you have and whether this may change in the next benefit year.
  • If you have a chronic condition, whether the Plan you choose covers your condition, and whether you are comfortable with the formulary that is applicable to your Plan (see pages 61-70 in your Member Guide for more information).

What must I consider before choosing a SELECT  Plan?

A SELECT  Plan should be considered:

  • If you are considering the Network, Traditional or Traditional Plus Plan and would like to maintain those benefits, but at a lower contribution rate;
  • If you are looking for more affordable options;
  • If you are comfortable using only the SELECT  hospitals;
  • If you are within comfortable travelling distance of one of the SELECT  list of hospitals; and/or
  • If your specialist works at one of the SELECT  list of hospitals, or if you are willing to move to a specialist who does work at one of the SELECT  list of hospitals.

 

If you are thinking of joining the Network or Network SELECT  Plan:

  • Check whether any non-PMB chronic medicine you may be on is covered.
  • Consider if there is a Universal Healthcare Network doctor within easy reach of your home or work. Please contact Universal Healthcare by emailing network.accounts@universal.co.za or calling 086 000 7769 for comprehensive lists of the nearest Universal Healthcare Network provider.
  • Take note that Universal Healthcare Network providers are mainly based within Southern Africa, therefore the Network or Network SELECT  Plan may not be appropriate for members who live in Namibia or other outlying countries.
  • You will need to reapply for Chronic Medicine approval.
  • Your savings balance will be paid out to you after 5 months. If you have funds in Unit Trusts, we will provide you with a selling form to facilitate the sale of your Unit Trusts.

If you are thinking of joining the Hospital Plan:

  • If you have a savings credit balance after 5 months, your savings balance will be paid out to you. If you have funds in Unit Trusts, we will provide you with a selling form to facilitate the sale of your Unit Trusts.

REMEMBER THAT YOU CANNOT CHANGE PLANS AT ANY OTHER TIME THAN AT THE BEGINNING OF THE BENEFIT YEAR, UNLESS YOU RETIRE OR YOU (OR A BENEFICIARY) ARE NEWLY REGISTERED ON THE ONCOLOGY PROGRAMME.

Who are the Fund's contracted providers, and what co-payments could I incur?

Why does the Fund make use of contracted providers?

The Fund contracts with certain providers to obtain efficient, cost effective healthcare services with quality outcomes for members. Depending on how the contract has been set up, these contracted providers are known as either designated service providers (DSPs) or preferred providers.

Why does the Fund make use of co-payments?

In an effort to manage escalating healthcare costs and over-utilisation of benefits, the Fund has implemented certain co-payments that would apply under certain circumstances. For ease of reference, this section gives an overview of all the co-payments that you may incur. Depending on your decisions, you may incur one or a combination of these.

GENERAL – MEDICAL SCHEME RATES (MSR) VS ACTUAL COSTS
Medical practitioners are under no obligation to charge MSR and often charge more. That means…

If you … … you will have to pay
claim for Hospital or Supplementary Benefits, (unless it is is in accordance with Prescribed Minimum Benefits), your claim will be covered at 1 x MSR, and… the difference between what you are charged by the medical service provider and 1 x MSR.
are on the Traditional or Traditional SELECT  Plan and claim for Day-to-Day Benefits after exhausting your Personal Medical Savings Account (PMSA) portion, your claim will be covered at 1 x Medical Scheme Rates (MSR) and… the difference between what you are charged by the medical service provider and 1 x MSR. (Medical practitioners are under no obligation to charge MSR and often charge substantially more.)
are on the Traditional Plus or Traditional Plus SELECT  Plan and claim for Day-to-Day Benefits after exhausting your Personal Medical Savings Account portion, your claim will be covered at up to 3 x Medical Scheme Rates (MSR) and… the difference between what you are charged by the medical service provider and 3 x MSR. (Medical practitioners are under no obligation to charge MSR and often charge substantially more.)

 

HOSPITALISATION

If you … … you will have a co-payment of Is there a contracted provider you can use to avoid the co-payment on the left?
are a member of the Network SELECT  , Traditional SELECT  or Traditional Plus SELECT  Plan and use a hospital that is not on the SELECT  list of hospitals* 20% of the total hospital bill* YES. The SELECT  list of hospitals, which have been chosen for both their efficiency and value for money (see page 141 in your Member Guide or use the online look-up tool).

 

If you … … you may have a co-payment of Is there a contracted provider you can use to avoid the co-payment on the left?
do not contact the Fund before you are admitted to hospital to pre-authorise your admission (unless it is a valid emergency) R500 NO

*This does not apply to members on the Savings, Traditional, Traditional SELECT , Traditional Plus and Traditional Plus SELECT  Plans for an admission for hip or knee surgery through ICPS or Jointcare.
 

PROCEDURES IN HOSPITAL

If you have any of the following procedures*… … you will have a co-payment of Is there a contracted provider you can use to avoid the co-payment on the left?
All Plans Non-PMB dental procedures in hospital R1 500 NO
Gastroscopy / colonoscopy / arthroscopy in hospital; cystoscopy, facet joint injections, flexible sigmoidoscopy, functional nasal surgery, hysteroscopy (not endometrial ablation), myringotomy, tonsillectomy and adenoidectomy, varicose vein surgery R1 500
Ultrasound scans (excl. pregnancy) R500 per beneficiary per day
Specialised radiology R1 500 per authorisation
Spinal surgery, if you decline participation in the Back and Neck Rehabilitation Programme before surgery R5 000 YES. Document Based Care (DBC) and physiotherapists following the South African Society of Physiotherapy defined care pathways are the Fund’s DSPs for the Back and Neck Rehabilitation Programme.
Laparoscopic appendectomy, laparoscopic hernia repair (for inguinal or femoral hernias: funding only if the hernia is bilateral or recurrent), laparoscopic hysterectomy, laparoscopic radical prostatectomy, balloon sinuplasty, diagnostic laparoscopy, percutaneous radiofrequency ablations (percutaneous rhizotomies), laparoscopic pyeloplasty, Nissen Fundoplication (reflux surgery) R3 500 NO. The alternative, if you do not want to incur the co-payment, would be to undergo open surgery.
Savings, Traditional, Traditional SELECT , Traditional Plus and Traditional Plus SELECT  Plans Hip or knee replacements not undertaken by the Fund’s Designated Service Providers R5 000 YES. ICPS and Jointcare, two groups of orthopaedic surgeons that specialise in performing hip and knee replacements according to standardised clinical care pathways, are the Fund’s DSPs.

*These co-payments will not apply if the procedure is in accordance with Prescribed Minimum Benefits. Please see page 104 in your Member Guide, PRESCRIBED MINIMUM BENEFITS, for more information.
 

APPLIANCES, TESTS, CONSULTATIONS

If you claim for … … you will have a co-payment of Is there a contracted provider you can use to avoid the co-payment on the left?
a consultation with a non-ICON oncologist 20% of the consultation claim YES. The Fund has appointed the Independent Clinical Oncology Network (ICON) as the DSP for Oncology treatment. ICON is a dedicated network of oncologists committed to the comprehensive management of members with cancer.
a hearing aid 10% of the cost of such hearing aid. NO
specialised radiology in or out of hospital R1 500 per authorisation NO
ultrasound scans in or out of hospital R500 per beneficiary per day

The co-payment will not be applicable to pregnancy related scans, oncology related scans, organ transplant related scans and the first mammogram.

NO
medical appliances 10% of the cost of such appliances, except if PMB NO

 

CHRONIC MEDICINES

If you claim for a medicine that is … … you will have a co-payment of Is there a contracted provider you can use to avoid the co-payment on the left?
not in your Plan Formulary 25% of the cost of such medicine. NO. If you do not want to incur the co-payment, use medicine in your Plan Formulary.
not on the Medicine Price List (MPL) the difference between the cost of the medicine and the reference (MPL) price. See page 63 in your Member Guide for more information. NO. If you do not want to incur the co-payment, use medicine on the Medicine Price List.

See page 61 in your Member Guide, CHRONIC BENEFITS, for more information.
 

PHARMACY CLAIMS

If you claim for … … then Is there a contracted provider you can use to avoid the co-payment on the left?
chronic medicine from a pharmacy that is not part of the Preferred Provider network of the Fund you may have a co-payment of the difference between the Fund’s agreed Preferred Provider dispensing rate and what the non-Preferred Provider pharmacy charges you. YES. There is an OMSMAF Preferred Provider pharmacy network. To find a provider visit the OMSMAF logged-in Member Zone website.
pharmacy-based Wellness Benefits such as screening tests or flu vaccines from a pharmacy that is not a Designated Service Provider of the Fund your benefit will be covered from your available Day-to-Day Benefits, instead of from your Wellness Benefits, unnecessarily depleting your Day-to-Day Benefits. YES. Clicks Pharmacies, Dis-Chem Pharmacies and Pick n Pay Pharmacies are the Fund’s Designated Service Providers for pharmacy-based Wellness Benefits.

 

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