Home | PLANS | HOSPITAL

HOSPITAL

A cost-effective, simple cover solution with essential in-hospital cover and basic chronic, wellness and supplementary benefits.

DAY-TO-DAY BENEFITS

Limited Primary Care Benefits for specified procedures only

  • R1 960 per family for specified procedures in doctors’ rooms only
  • Specified procedures in doctors’ rooms subject to Primary Care Benefits (PCB) limit

MANAGED CARE BENEFITS

The Old Mutual Staff Medical Aid Fund aims to identify and manage beneficiaries’ disease risks. The Fund has a number of programmes that form part of the Managed Care approach

  • Back and Neck Rehabilitation Programme
  • Oncology Benefit Management Programme
  • HIV and AIDS Management Programme
  • Mental Health Programme
  • Active Disease Risk Management Programme

HOSPITAL BENEFITS

Overall Annual Limit (OAL): R500 000 per beneficiary per benefit year

  • R1 000 000 per family per benefit year, subject to certain sub-limits. Unlimited PMB if obtained from a DSP
  • Sub-limits apply:
    • Basic pathology: R18 000 per family per benefit year
    • Basic radiology: R24 250 per family per benefit year
    • Physiotherapy: R5 300 per family per benefit year
  • Oncology covered within ICON Essential Protocols

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.

SUPPLEMENTARY BENEFITS

  • Limited, paid at 1 x MSR
  • Ultrasound scans in and out of hospital (other than for pregnancy) – combined benefit limit: R4 790 per family per benefit year
  • Specialised Radiology in and out of hospital (including MRI, CT and Radio-isotope Scans and Nuclear Medicine) – combined benefit limit: R14 100 per family per benefit year, with a co-payment of R1 500 per authorisation
  • Back and Neck Rehabilitation Programme
  • Mental Health Programme: R10 500 per beneficiary per benefit year

CHRONIC BENEFITS

Restrictive Formulary

  • Non-PMB conditions: A limit of R5 030 per family (for Chronic Hepatitis, Depression, Macular Degeneration and Oedema, Anxiety and Post-Traumatic Stress Disorder only), subject to Maximum Medical Aid Price (MMAP) or the Medicine Price, whichever is the lesser
  • PMB conditions: Unlimited, subject to the Universal Healthcare restrictive formulary and approval

MATERNITY BENEFITS

  • All pregnant beneficiaries have to register on the Mother and Baby Care Programme
  • If you are on the Network (including SELECT) or Hospital Plan, you will not have additional benefits, but you will receive educational support and relevant contact information

Excludes:

  • Antenatal classes and visits
  • Ultrasound scans
  • Out-of-hospital pathology tests
  • Antenatal vitamins

WELLNESS BENEFITS

  • 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 (available from Clicks, Dis-Chem and Pick n Pay Pharmacy clinics)
  • Contraceptive benefit: R2 990 per beneficiary per benefit year. R1 880 sub-limit for oral contraceptives
  • Non-pharmacy based benefits:
    • One pap smear and mammogram per female beneficiary per benefit year
    • One prostate test per male beneficiary
    • Colorectal screening, limited to one test per beneficiary per benefit year
    • 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
  • Hearing screening for newborns up to six weeks
  • PAED-IQ’s Babyline – A 24/7, paediatric telephone service, whereby parents or caregivers of children from birth to three years of age registered on the Fund can phone in and get up-to-date child healthcare advice and reassurance

NOTE: Please ask the General Practitioner, Gynaecologist or Urologist (whichever is applicable) to submit the wellness consultation claim using the following primary ICD-10 code: Z00.0. If this code is not used, the benefit will be paid from your available Day-to-Day Benefits.

WANT TO KNOW MORE?

Click here for the full membership guide.

Home | PLANS | HOSPITAL

HOSPITAL

A cost-effective, simple cover solution with essential in-hospital cover and basic chronic, wellness and supplementary benefits.

DAY-TO-DAY BENEFITS

 

Limited Primary Care Benefits for specified procedures only

  • R1 960 per family for specified procedures in doctors’ rooms only
  • Specified procedures in doctors’ rooms subject to Primary Care Benefits (PCB) limit

MANAGED CARE BENEFITS

The Old Mutual Staff Medical Aid Fund aims to identify and manage beneficiaries’ disease risks. The Fund has a number of programmes that form part of the Managed Care approach

  • Back and Neck Rehabilitation Programme
  • Oncology Benefit Management Programme
  • HIV and AIDS Management Programme
  • Mental Health Programme
  • Active Disease Risk Management Programme

HOSPITAL BENEFITS

Overall Annual Limit (OAL): R500 000 per beneficiary per benefit year

  • R1 000 000 per family per benefit year, subject to certain sub-limits. Unlimited PMB if obtained from a DSP
  • Sub-limits apply:
    • Basic pathology: R18 000 per family per benefit year
    • Basic radiology: R24 250 per family per benefit year
    • Physiotherapy: R5 300 per family per benefit year
  • Oncology covered within ICON Essential Protocols

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.

SUPPLEMENTARY BENEFITS

  • Limited, paid at 1 x MSR
  • Ultrasound scans in and out of hospital (other than for pregnancy) – combined benefit limit: R4 790 per family per benefit year
  • Specialised Radiology in and out of hospital (including MRI, CT and Radio-isotope Scans and Nuclear Medicine) – combined benefit limit: R14 100 per family per benefit year, with a co-payment of R1 500 per authorisation
  • Back and Neck Rehabilitation Programme
  • Mental Health Programme: R10 500 per beneficiary per benefit year

CHRONIC BENEFITS

Restrictive Formulary

  • Non-PMB conditions: A limit of R5 030 per family (for Chronic Hepatitis, Depression, Macular Degeneration and Oedema, Anxiety and Post-Traumatic Stress Disorder only), subject to Maximum Medical Aid Price (MMAP) or the Medicine Price, whichever is the lesser
  • PMB conditions: Unlimited, subject to the Universal Healthcare restrictive formulary and approval

MATERNITY BENEFITS

  • All pregnant beneficiaries have to register on the Mother and Baby Care Programme
  • If you are on the Network (including SELECT) or Hospital Plan, you will not have additional benefits, but you will receive educational support and relevant contact information

Excludes:

  • Antenatal classes and visits
  • Ultrasound scans
  • Out-of-hospital pathology tests
  • Antenatal vitamins

WELLNESS BENEFITS

  • 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 (available from Clicks, Dis-Chem and Pick n Pay Pharmacy clinics)
  • Contraceptive benefit: R2 990 per beneficiary per benefit year. R1 880 sub-limit for oral contraceptives
  • Non-pharmacy based benefits:
    • One pap smear and mammogram per female beneficiary per benefit year
    • One prostate test per male beneficiary
    • Colorectal screening, limited to one test per beneficiary per benefit year
    • 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
  • Hearing screening for newborns up to six weeks
  • PAED-IQ’s Babyline – A 24/7, paediatric telephone service, whereby parents or caregivers of children from birth to three years of age registered on the Fund can phone in and get up-to-date child healthcare advice and reassurance

NOTE: Please ask the General Practitioner, Gynaecologist or Urologist (whichever is applicable) to submit the wellness consultation claim using the following primary ICD-10 code: Z00.0. If this code is not used, the benefit will be paid from your available Day-to-Day Benefits.

WANT TO KNOW MORE?

Click here for the full membership guide.