TRADITIONAL SELECT
A complete cover solution with fully comprehensive, unlimited in-hospital cover, comprehensive chronic and supplementary benefits, standard wellness benefits and comprehensive day-to-day benefits. Get all this cover at a lower cost based on a restriction to select hospital providers.
DAY-TO-DAY BENEFITS
Comprehensive
- 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):
- GP and specialist consultations
- Specified procedures in general practitioners’ and specialists’ rooms
- Pathology
- Radiology
- Acute medicine paid at 100% of MMAP or medicine price, whichever is the lesser.
- Pharmacy-Advised Therapy (PAT)
- Basic and advanced Dentistry
- Psychology
- Physiotherapy
- Auxiliary services
- Optometry
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
Comprehensive with unlimited overall annual limit (subject to certain sub-limits)
- Unlimited Prescribed Minimum Benefits (PMB) if obtained from a Designated Service Provider (DSP)
- Sub-limits apply
- Oncology covered within ICON Enhanced Protocols (higher benefit sub-limit)
Note: Under the SELECT Plan, members’ choice of hospitals is restricted.
SUPPLEMENTARY BENEFITS
Comprehensive, paid at 1 x MSR
- Maternity benefits
- Ultrasound scans in and out of hospital (other than for pregnancy) combined benefit limit: R7 480 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: R18 200 per family per benefit year, with a co-payment of R1 500 per authorisation
- Dental implants: R15 200 per family per benefit year
- Medical appliances: R10 100 per family per benefit year, subject to approval
- Foot orthotics: R4 570 per family and included in the appliance limit of R10 100 per family above
- Hearing aids and repairs:
- R18 000 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: 1 x MSR or cost, whichever is the lesser, up to a sublimit of R16 000 per beneficiary per benefit year
- Mental Health Programme: R11 000 per beneficiary per benefit year
- Back and Neck Rehabilitation programme
CHRONIC BENEFITS
Comprehensive
- Non-PMB conditions: A limit of R12 800 per family per benefit year, subject to chronic medicine benefit, chronic disease lists and approval
- PMB conditions: Universal Healthcare Comprehensive Formulary will apply
MATERNITY BENEFITS
- All pregnant beneficiaries have to register on the Mother and Baby Care Programme
- Antenatal classes: R2 100 per family per benefit year
- Antenatal visits: R5 270 per pregnancy
- Ultrasound scans: Two 2-D scans per beneficiary
- Out-of-hospital pathology tests: R3 260 per family per benefit year
- Antenatal vitamins: 100% of MMAP or Medicine Price, subject to prescription from an approved list and included in the Hospital Benefit
- Doula (birthing coach) as part of maternity benefits in hospital: R2 500 per pregnancy
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
- 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
- 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 the recommendation of the Department of Health.
- Pre-school eye and hearing screening: For children aged 5 and 6
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.
TRADITIONAL SELECT
A complete cover solution with fully comprehensive, unlimited in-hospital cover, comprehensive chronic and supplementary benefits, standard wellness benefits and comprehensive day-to-day benefits. Get all this cover at a lower cost based on a restriction to select hospital providers.
DAY-TO-DAY BENEFITS
Comprehensive
- 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):
- GP consultations
- uConsult Virtual Consultation
- Specialist consultations (subject to GP referral and authorization)
- Specified procedures in general practitioners’ and specialists’ rooms
- Pathology
- Radiology
- Acute medicine paid at 100% of MMAP or medicine price, whichever is the lesser.
- Vitamins paid at 100% of cost or Medicine Price whichever is the lesser, paid from PMSA only and excluded from PCB.
- Pharmacy-Advised Therapy (PAT)
- Basic and advanced Dentistry
- Psychology
- Physiotherapy
- Auxiliary services
- Optometry
MANAGED CARE BENEFITS
- 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
Comprehensive with unlimited overall annual limit (subject to certain sub-limits)
- Unlimited Prescribed Minimum Benefits (PMB) if obtained from a Designated Service Provider (DSP)
- Sub-limits apply
- Oncology covered within ICON Enhanced Protocols (higher benefit sub-limit)
- Quro Medical – The technology-enabled Hospital at Home (HAH) gives patients the option to receive active treatment for a specified period at home instead of a general hospital ward, without compromising on the quality of care. Subject to referral from treating doctor.
- Note: Under the SELECT Plan, members’ choice of hospitals is restricted.
SUPPLEMENTARY BENEFITS
Comprehensive, paid at 1 x MSR
- Maternity benefits
- Ultrasound scans in and out of hospital (other than for pregnancy) combined benefit limit: R7 800 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: R19 000 per family per benefit year, with a co-payment of R1 500 per authorisation.
- Dental implants: R15 900 per family per benefit year.
- Medical appliances: R10 500 per family per benefit year, subject to approval.
- Foot orthotics: R4 770 per family and included in the appliance limit of R10 500 per family above.
- Hearing aids and repairs: R18 800 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: 1 x MSR or cost, whichever is the lesser, up to a sublimit of R16 700 per beneficiary per benefit year.
- Mental Health Programme: R11 500 per beneficiary per benefit year.
- Back and Neck Rehabilitation programme
CHRONIC BENEFITS
Comprehensive
- Non-PMB conditions:A limit of R13 400 per family per benefit year, subject to chronic medicine benefit, Chronic Disease Lists and approval.
- PMB conditions:Unlimited, subject to the Universal Healthcare comprehensive formulary and approval.
MATERNITY BENEFITS
- All pregnant beneficiaries have to register on the Mother and Baby Care Programme
- Antenatal classes: R2 190 per family per benefit year
- Antenatal visits: R5 500 per pregnancy.
- Ultrasound scans: Two 2-D scans per beneficiary
- Out-of-hospital pathology tests: R3 400 per family per benefit year.
- Antenatal vitamins: 100% of MMAP or Medicine Price, subject to prescription from an approved list and included in the Hospital Benefit
- Doula (birthing coach) as part of maternity benefits in hospital: subject to a limit of R2 610 per pregnancy, specifically for the confinement (delivery). No post-natal follow-ups.
WELLNESS BENEFITS
(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: R3 260 per beneficiary per benefit year. R2 050 sub-limit per beneficiary 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
- Health Risk assessment – limited to 1 test per beneficiary per benefit year. Only for services rendered by a registered healthcare practitioner (for example, 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 the Universal Healthcare network of dieticians for annual assessment, healthy eating plan prescription and regular monitoring. An additional assessment for pregnant beneficiaries.
- Childhood immunisations 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.
- Fitness Assessment and Exercise Prescription Benefit: 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.
- 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, 3 PCR tests and Chest physiotherapy. Pre-authorisation and managed care protocols apply.
IMPORTANT: 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.
