SAVINGS
A simple cover solution with a savings account. Get limited in-hospital cover, basic chronic, wellness, supplementary and day-to-day benefits, with the added benefit of a personal medical savings account.
DAY-TO-DAY BENEFITS
- Limited to Personal Medical Savings Account only, no PCB limits
- At 100% of cost from PMSA and then from accumulated savings, subject to available funds
- The following services are covered at cost from your PMSA or accumulated savings, subject to available funds:
- GP and specialist consultations
- Pathology
- Radiology
- Acute medicine paid at 100% of cost or Medicine Price, whichever is the lesser
- Dentistry
- Optometry
- Psychology and psychiatry
- Physiotherapy
- Auxiliary services
- Specified procedures in doctors’ rooms
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
- Mother and Baby Care Programme
HOSPITAL BENEFITS
Annual Limit (OAL): R750 000 per beneficiary per benefit year
- R1 500 000 per family per benefit year for hospital benefits (HB), subject to certain sub-limits
- Unlimited Prescribed Minimum Benefits (PMB) is obtained from a Designated Service Provider (DSP)
- Oncology covered within ICON Enhanced Protocols
Sub-limits apply:
- Basic pathology: R18 900 per family per benefit year
- Basic radiology: R25 400 per family per benefit year
- Physiotherapy: R5 550 per family per benefit year
SUPPLEMENTARY BENEFITS
- Paid at 1 x MSR
- Ultrasound scans in and out of hospital
- Specialised Radiology in and out of hospital
- Maternity benefit
CHRONIC BENEFITS
Non-PMB conditions: A limit of R5 270 per family
- 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
- For other conditions, subject to available PMSA or, thereafter, accumulated savings
PMB Conditions:
- Unlimited, subject to the Universal restrictive formulary and approval.
MATERNITY BENEFITS
- All pregnant beneficiaries have to register on the Mother and Baby Care Programme
- Antenatal classes: R1 340 per family per benefit year
- Antenatal visits: R3 160 per pregnancy
- Ultrasound scans (pregnancy): Two 2-D scans per beneficiary
- Out-of-hospital pathology tests (pregnancy): R2 610 per family per benefit year
- Antenatal vitamins: 100% of MMAP or Medicine Price, whichever is the lesser, subject to the prescription from an approved list and included in the Hospital Benefit
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: R3 130 per beneficiary per benefit year. R1 970 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
- Nutritional assessment and healthy eating plan – Access to Universal network of dieticians for annual assessment, healthy eating plan prescription and regular monitoring
- Childhood immunisations – Applicable to children up to the age of 12 years, as per recommendation of the Department of Health
- Pre-school eye and hearing screening – For children aged 5 and 6
- 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.
SAVINGS
A simple cover solution with a savings account. Get limited in-hospital cover, basic chronic, wellness, supplementary and day-to-day benefits, with the added benefit of a personal medical savings account.
DAY-TO-DAY BENEFITS
- Limited to Personal Medical Savings Account only, no PCB limits
- At 100% of cost from PMSA and then from accumulated savings, subject to available funds
- The following services are covered at cost from your PMSA or accumulated savings, subject to available funds:
- GP and specialist consultations
- Pathology
- Radiology
- Acute medicine paid at 100% of cost or Medicine Price, whichever is the lesser
- Dentistry
- Optometry
- Psychology and psychiatry
- Physiotherapy
- Auxiliary services
- Specified procedures in doctors’ rooms
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
- Mother and Baby Care Programme
HOSPITAL BENEFITS
Unlimited overall annual limit (subject to certain sub-limits)
- Unlimited Prescribed Minimum Benefits (PMB) is obtained from a Designated Service Provider (DSP)
- Oncology covered within ICON Enhanced Protocols
- Basic pathology: Subject to the Overall Annual Limit and Managed Care protocols
- Basic radiology: Unlimited subject to the Overall Annual Limit and Managed Care protocols
- Physiotherapy: R5790 per family per benefit year
- Quro (home-based monitoring service) Medical benefit. This benefit allows you to return home from hospital sooner. Member can recover in their own home while still being closely monitored 24 hours-a-day by a team of medical professionals.
SUPPLEMENTARY BENEFITS
- Paid at 1 x MSR
- Ultrasound scans in and out of hospital
- Specialised Radiology in and out of hospital
- Maternity benefits
CHRONIC BENEFITS
Non-PMB conditions: A limit of R5 500 per family
- Chronic Hepatitis, Depression, Macular Degeneration and Oedema, Anxiety and Post-Traumatic Stress Disorder, Acne, Allergic Rhinitis, Cardiac Arrhythmia, Gout, Female Hormone Replacement Therapy, Migraine and Oestoarthritis.
- Subject to Maximum Medical Aid Price (MMAP) or the Medicine Price.
- For other conditions, subject to available PMSA or, thereafter, accumulated savings.
PMB Conditions:
- Unlimited, subject to the Universal restrictive formulary and approval.
MATERNITY BENEFITS
- All pregnant beneficiaries have to register on the Mother and Baby Care Programme
- Antenatal classes: R1 400 per family per benefit year
- Antenatal visits: R3 300 per pregnancy
- Ultrasound scans (pregnancy): Two 2-D scans per beneficiary
- Out-of-hospital pathology tests (pregnancy): R2 720 per family per benefit year
- Antenatal vitamins: 100% of MMAP or Medicine Price, whichever is the lesser, subject to the prescription from an approved list and included in the Hospital Benefit
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
- Contraceptive benefit: R3 260 per beneficiary per benefit year. R2 050 sub-limit for oral contraceptives
- Non-pharmacy based benefits:
- One pap smear and mammogram per female beneficiary per benefit year
- One prostate specific antigen 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
- Nutritional assessment and healthy eating plan – Access to Universal network of dieticians for annual assessment, healthy eating plan prescription and regular monitoring
- Childhood immunisations – Applicable for children up to the age of 12 years, as per recommendation of the Department of Health
- Pre-school eye and hearing screening – For children aged 5 and 6
- 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
- COVID-19 Benefit Package: Any beneficiary who tested positive for COVID-19 will be able to access the following: Pulse oximeter, Nebuliser, Oxygenator, Thermometer, 2 GP consultations and Chest physiotherapy. Pre-authorisation and managed care protocols apply.
- COVID-19 Vaccine: 1 vaccination per eligible adult beneficiary.
- Fitness Assessment and Exercise Prescription benefit: Only available on the Traditional and Traditional Plus Plans, members will have access to the Universal Healthcare network of Biokineticists, who will assess the members’ needs and prescribe a relevant exercise plan that can be filled at a contracted fitness facility. This benefit will be paid from the Wellness Benefit. It is subject to registration on the program and Universal Healthcare protocols.
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 Benefit
WANT TO KNOW MORE?
Click here for the full membership guide.
