> Member contributions - 2012
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HEALTHPACT PREMIUM |
HEALTHPACT SILVER |
HEALTHPACT SELECT |
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Hospital plan only |
Hospital plan with Medical Savings Account (MSA)
|
Hospital plan with day-to-day benefits and Medical Savings Account (MSA)
|
| Principal member |
R825 |
R1,085 (including R200 savings per month) |
R3,115 (including R259 savings per month) |
| Adult beneficiary |
R825 |
R1,085 (including R200 savings per month) |
R3,115 (including R259 savings per month) |
| Minor beneficiary |
R138 |
R163 (including R30 savings per month) |
R507 (including R42 savings per month) |
Medical Savings Account (MSA)
|
None |
Compulsory savings included in contribution |
Compulsory savings included in contribution |
> Hospitalisation
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HEALTHPACT PREMIUM |
HEALTHPACT SILVER |
HEALTHPACT SELECT |
| Overall annual limit |
Unlimited |
Unlimited |
Unlimited |
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Hospital accommodation
(Ward fees, operating theatres, unattached theatres and day hospitals)
|
Up to 100% of the CMP tariff or Agreed Tariff in intensive care, specialised intensive care, high care and general wards (subject to pre-authorisation) |
Up to 100% of the CMP tariff or Agreed Tariff in intensive care, specialised intensive care, high care and general wards (subject to pre-authorisation) |
Up to 100% of the CMP tariff or Agreed Tariff in intensive care, specialised intensive care, high care and general wards (subject to pre-authorisation) |
| Emergency room treatment only (Outpatient services) |
No cover, except for PMBs |
Payable from MSA - except for PMBs |
Payable from MSA, thereafter from day-to-day pool - except for PMBs |
| Hospitalisation/ institutionalisation for treatment of non-PMB mental illness, alcoholism and drug addiction |
No cover, except for PMBs (subject to pre-authorisation) |
Payable from MSA - except for PMBs (subject to pre-authorisation) |
Payable from MSA, thereafter from day-to-day pool - except for PMBs (subject to pre-authorisation)
|
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Treatment in lieu of hospitalisation
(Registered step-down facilities, hospices, registered nurses and rehabilitation centres when hospitalisation is not clinically appropriate)
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100% of CMP tariff for hospices and registered nurses, limited to 15 days per beneficiary (subject to pre-authorisation) |
100% of CMP tariff for hospices and registered nurses, limited to 15 days per beneficiary (subject to pre-authorisation) |
100% of CMP tariff for hospices and registered nurses, limited to 15 days per beneficiary (subject to pre-authorisation) |
| Emergency services (Provided by a registered ambulance service) |
100% of CMP tariff - except for PMBs (subject to pre-authorisation) |
100% of CMP tariff - except for PMBs (subject to pre-authorisation) |
100% of CMP tariff - except for PMBs (subject to pre-authorisation) |
Blood transfusions
(In hospital) |
100% of cost to a maximum of 100% of CMP tariff (subject to pre-authorisation) |
100% of cost to a maximum of 100% of CMP tariff (subject to pre-authorisation) |
100% of cost to a maximum of 100% of CMP tariff (subject to pre-authorisation) |
| Materials and devices (Used in hospital) |
100% of cost to a maximum of Single Exit Price/Agreed Tariff/pre-authorised tariff (subject to pre-authorisation) |
100% of cost to a maximum of Single Exit Price/Agreed Tariff/pre-authorised tariff (subject to pre-authorisation) |
100% of cost to a maximum of Single Exit Price/Agreed Tariff/pre-authorised tariff (subject to pre-authorisation) |
|
Medicines
(Dispensed and used in hospital)
|
100% of cost, up to the Single Exit Price for approved medicines (subject to pre-authorisation) |
100% of cost, up to the Single Exit Price for approved medicines (subject to pre-authorisation) |
100% of cost, up to the Single Exit Price for approved medicines (subject to pre-authorisation) |
In-hospital biokineticis and physiotherapy
|
100% of CMP tariff (subject to pre-authorisation) |
100% of CMP tariff (subject to pre-authorisation) |
100% of CMP tariff (subject to pre-authorisation) |
| In-hospital consultations, procedures and operations performed by general practitioners |
200% of CMP tariff (subject to pre-authorisation) |
100% of CMP tariff (subject to pre-authorisation) |
200% of CMP tariff (subject to pre-authorisation) |
| In-hospital consultations, procedures and operations performed by registered medical specialists |
200% of CMP tariff (subject to pre-authorisation) |
100% of CMP tariff (subject to pre-authorisation) |
200% of CMP tariff (subject to pre-authorisation) |
| Laparoscopic and endoscopic procedures performed in hospital |
200% of CMP tariff. Laparoscopic procedures as per the endoscopic surgeon’s guidelines with a co-payment (co-payments are the same across all three plans – click here to view them in a pop-up window) (subject to pre-authorisation) |
100% of CMP tariff. Laparoscopic procedures as per the endoscopic surgeon’s guidelines with a co-payment (co-payments are the same across all three plans – click here to view them in a pop-up window) (subject to pre-authorisation) |
200% of CMP tariff. Laparoscopic procedures as per the endoscopic surgeon’s guidelines with a co-payment (co-payments are the same across all three plans – click here to view them in a pop-up window) (subject to pre-authorisation) |
> Consultations and out-of-hospital procedures – GPs, specialists, biokineticists and physiotherapists
| |
HEALTHPACT PREMIUM |
HEALTHPACT SILVER |
HEALTHPACT SELECT |
General practitioner consultations and procedures
|
No cover, except for PMBs (subject to pre-authorisation) |
Up to two GP visits per beneficiary per year, at 100% of CMP tariff, thereafter payable from MSA - except for PMBs (subject to pre-authorisation) |
200% of CMP tariff, payable from MSA, thereafter from day-to-day pool - except for PMBs (subject to pre-authorisation) |
Registered medical specialist consultations and procedures
|
No cover, except for PMBs (subject to pre-authorisation) |
Payable from MSA - except for PMBs (subject to pre-authorisation) |
Payable from MSA, thereafter from day-to-day pool - except for PMBs (subject to pre-authorisation) |
Out-of-hospital laparoscopic and endoscopic procedures
|
200% of CMP tariff. Laparoscopic procedures as per the endoscopic surgeon’s guidelines with a co-payment (co-payments are the same across all three plans – click here to view them in a pop-up window) (subject to pre-authorisation) |
100% of CMP tariff. Laparoscopic procedures as per the endoscopic surgeon’s guidelines with a co-payment (co-payments are the same across all three plans – click here to view them in a pop-up window) (subject to pre-authorisation) |
200% of CMP tariff. Laparoscopic procedures as per the endoscopic surgeon’s guidelines with a co-payment (co-payments are the same across all three plans – click here to view them in a pop-up window) (subject to pre-authorisation) |
Out-of-hospital biokinetics and physiotherapy
|
No cover, except for PMBs (subject to pre-authorisation) |
Payable from MSA - except for PMBs (subject to pre-authorisation) |
Payable from MSA, thereafter from day-to-day pool - except for PMBs (subject to pre-authorisation) |
> Dentistry, orthodontics and oral surgery
| |
HEALTHPACT PREMIUM |
HEALTHPACT SILVER |
HEALTHPACT SELECT |
| General dental practitioner consultations |
No cover |
100% of CMP tariff limited to R320 per beneficiary, thereafter payable from MSA - except for PMBs (subject to pre-authorisation) |
Payable from MSA, thereafter from day-to-day pool - except for PMBs (subject to pre-authorisation) |
| Orthodontic treatment |
No cover |
Payable from MSA |
Payable from MSA, thereafter from
day-to-day pool |
| Maxillo-facial surgeons (In-hospital procedures) |
120% of CMP tariff - except for PMBs (subject to pre-authorisation) |
100% of CMP tariff - except for PMBs (subject to pre-authorisation) |
120% of CMP tariff - except for PMBs (subject to pre-authorisation) |
Maxillo-facial surgeons and orthodontists
(Dental implants, general dental treatment, orthodontic treatment, orthognathic procedures, periodontic treatment and prosthodontic treatment) |
No cover |
Payable from MSA |
Payable from MSA, thereafter from
day-to-day pool |
> Maternity and paediatrics
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HEALTHPACT PREMIUM |
HEALTHPACT SILVER |
HEALTHPACT SELECT |
Maternity confinements
(Birth or delivery)
|
200% of CMP tariff; only medically-necessary caesareans are covered - except for PMBs (subject to pre-authorisation) |
100% of CMP tariff; only medically-necessary caesareans are covered - except for PMBs (subject to pre-authorisation) |
200% of CMP tariff; only medically-necessary caesareans are covered - except for PMBs (subject to pre-authorisation) |
Ante-natal consultations and foetal scans
(In or out of hospital)
|
200% of the CMP tariff, limited to R1,600 per family per year - except for PMBs |
100% of the CMP tariff, limited to R1,600 per family per year, thereafter payable from MSA - except for PMBs |
200% of the CMP tariff, limited to R2,000 per family per year, thereafter payable from MSA and then from day-to-day pool - except for PMBs |
Paediatrician consultations
(In or out of hospital)
|
200% of CMP tariff, limited to R1,270 per child per year - except for PMBs |
100% of the CMP tariff, limited to R640 per child per year, thereafter payable from MSA - except for PMBs |
200% of the CMP tariff, payable from MSA, thereafter from day-to-day pool - except for PMBs |
| Paediatrician procedures and operations |
200% of CMP tariff (subject to pre-authorisation) |
100% of CMP tariff (subject to pre-authorisation) |
200% of CMP tariff (subject to pre-authorisation) |
> Diagnostics – x-rays, radiology and pathology
| |
HEALTHPACT PREMIUM |
HEALTHPACT SILVER |
HEALTHPACT SELECT |
| Radiologist procedures, (Angiograms, CT scans, duplex doppler scans, interventional radiology, MRI scans, and nuclear medical investigations) |
100% of CMP tariff, limited to R6,000 per beneficiary per year, with a co-payment of R1,500 per event on all procedures - except for PMBs (subject to pre-authorisation) |
100% of CMP tariff, limited to R6,000 per beneficiary per year, with a co-payment of R1,500 per event on all procedures, thereafter payable from MSA - except for PMBs (subject to pre-authorisation) |
100% of CMP tariff, limited to R6,000 per beneficiary per year, with a co-payment of R1,500 per event on all procedures, thereafter payable from MSA and then from day-to-day pool - except for PMBs (subject to pre-authorisation) |
| Black and white x-rays (In hospital) |
100% of CMP tariff (subject to pre-authorisation) |
100% of CMP tariff (subject to pre-authorisation) |
100% of CMP tariff (subject to pre-authorisation) |
| Black and white x-rays (Out of hospital) |
No cover, except for PMBs (subject to pre-authorisation) |
Payable from MSA - except for PMBs |
Payable from MSA, thereafter from day-to-day pool - except for PMBs |
Pathology services
(With Pathcare/Lancet Laboratories; with GP referral) |
100% of CMP tariff |
100% of CMP tariff |
100% of CMP tariff |
> Prostheses, dialysis, organ transplants and oncology
| |
HEALTHPACT PREMIUM |
HEALTHPACT SILVER |
HEALTHPACT SELECT |
| Prostheses and implants, excluding hearing devices and dental implants |
If introduced internally as an integral part of an operation, 100% of cost, subject to CMP’s prosthetic price list. Limited to R35,000 per beneficiary per year (subject to pre-authorisation) |
If introduced internally as an integral part of an operation, 100% of cost, subject to CMP’s prosthetic price list. Limited to R35,000 per beneficiary per year (subject to pre-authorisation) |
If introduced internally as an integral part of an operation, 100% of cost, subject to CMP’s prosthetic price list. Limited to R35,000 per beneficiary per year (subject to pre-authorisation) |
| External prostheses and surgical appliances (e.g. wheelchairs, crutches, etc.) |
No cover, except for PMBs (subject to pre-authorisation) |
100% of cost, payable from MSA - except for PMBs (subject to pre-authorisation) |
Payable from MSA, thereafter from day-to-day pool - except for PMBs (subject to pre-authorisation) |
| Chronic renal dialysis |
Provided that requirements are met and treatment is provided by a Preferred Provider, covered at 100% of CMP tariff - except for PMBs (subject to pre-authorisation) |
Provided that requirements are met and treatment is provided by a Preferred Provider, covered at 100% of CMP tariff - except for PMBs (subject to pre-authorisation) |
Provided that requirements are met and treatment is provided by a Preferred Provider, covered at 100% of CMP tariff - except for PMBs (subject to pre-authorisation) |
| Organ transplants |
Provided that requirements are met and treatment is provided by a Preferred Provider, covered at 100% of CMP tariff - except for PMBs (subject to pre-authorisation) |
Provided that requirements are met and treatment is provided by a Preferred Provider, covered at 100% of CMP tariff - except for PMBs (subject to pre-authorisation) |
Provided that requirements are met and treatment is provided by a Preferred Provider, covered at 100% of CMP tariff - except for PMBs (subject to pre-authorisation) |
| Oncology treatment |
Provided that requirements are met and treatment is provided by a Preferred Provider, covered at 100% of CMP tariff, as per the SA Oncology Consortium’s Tier 1 treatment guidelines - except for PMBs (treatment plan subject to approval and pre-authorisation) |
Provided that requirements are met and treatment is provided by a Preferred Provider, covered at 100% of CMP tariff, as per the SA Oncology Consortium’s Tier 1 treatment guidelines - except for PMBs (treatment plan subject to approval and pre-authorisation) |
Provided that requirements are met and treatment is provided by a Preferred Provider, covered at 100% of CMP tariff, as per the SA Oncology Consortium’s Tier 1 and 2 treatment guidelines - except for PMBs (treatment plan subject to approval and pre-authorisation) |
| Anti-emetics and vitamins forming part of oncology treatment |
No cover, except for PMBs (subject to pre-authorisation) |
Payable from MSA - except for PMBs |
Payable from MSA, thereafter from day-to-day pool - except for PMBs |
> Prescribed medication
| |
HEALTHPACT PREMIUM |
HEALTHPACT SILVER |
HEALTHPACT SELECT |
| Chronic medication |
100% of cost to a maximum of Single Exit Price plus the Preferred Provider dispensing fee (subject to chronic programme protocols) |
100% of cost to a maximum of Single Exit Price plus the Preferred Provider dispensing fee (subject to chronic programme protocols) |
100% of cost to a maximum of Single Exit Price plus the Preferred Provider dispensing fee (subject to chronic programme protocols) |
| Acute medication |
No cover, except for PMBs |
100% of cost to a maximum of Single Exit Price, plus the agreed Preferred Provider dispensing fee. Limited to R320 per family; thereafter payable from MSA - except for PMBs |
100% of cost to a maximum of Single Exit Price, plus the agreed Preferred Provider dispensing fee. Payable from MSA, thereafter from day-to-day pool - except for PMBs |
| Take-home medication |
No cover |
Payable from MSA - except for PMBs |
Payable from MSA, thereafter from day-to-day pool - except for PMBs |
> Spectacles, contact lenses and supplementary services
| |
HEALTHPACT PREMIUM |
HEALTHPACT SILVER |
HEALTHPACT SELECT |
| Spectacles and contact lenses |
No cover |
100% of cost, payable from MSA - except for PMBs |
100% of cost, payable from MSA, thereafter from day-to-day pool - except for PMBs |
Supplementary services
|
No cover, except for PMBs |
100% of cost, payable from MSA - except for PMBs |
100% of cost, payable from MSA, thereafter from day-to-day pool - except for PMBs |
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