Savings Plan

MANAGED CARE

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.

SUPPLEMENTARY

• Specialised Radiology R17 900 pfpa (co-payment of R1 500 per scan for non-PMBs).
• Ultrasound scans (non-pregnancy) R6 080 pfpa.
• Maternity Benefits (Antenatal classes/visits, 2D-scans, vitamins, pathology tests).

MATERNITY

• All pregnant beneficiaries have to register on the Mother and Baby Care Programme.
  Antenatal classes: R1 620 per family per benefit year.
• Antenatal visits: 8 visits per pregnancy, paid at MSR.
• Ultrasound scans (pregnancy): Two 2-D scans per beneficiary.
• Out-of-hospital pathology tests (pregnancy): R3 150 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.
• A Doula (birthing coach): as part of the in-hospital maternity benefit, subject to a limit of R3 030 per pregnancy for delivery only.

WELLNESS

• 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 780 per beneficiary per benefit year. R2 370 sub-limit for oral contraceptives.

• Non-pharmacy based benefits:
  • *NEW! One consultation per beneficiary per benefit year with a GP paid at 100% of MSR or a Gynaecologist or a Urologist or a Dermatologist paid at 200% of MSR from the Wellness benefit for any of the following non-pharmacy screenings benefits:
  • One Pap smear, Mammogram, Syphilis and Chlamydia infection screening, limited to 1 test per female beneficiary, including consultation with a Gynaecologist or General Practitioner. (Please note for the Pap smear, Mammogram and Syphilis and Chlamydia screening, only one Gynaecologist consultation per benefit year will be funded from the Screening Benefit.)
    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.
  • Dental caries (prevention and oral fluoride supplementation): limited to beneficiaries up to age 6 years, subject to Managed Care Protocols, including oral-hygienist consultation.
  • COVID-19 Vaccine: Vaccinations for all eligible beneficiaries in accordance with the Department of Health recommendation.
  • Dermatologist Consultation – limited to 1 consultation for cancer screening per beneficiary every 2 years, for beneficiaries 35-years and older
  • Bone Density Scan – limited to 1 bone density scan per beneficiary, per annum
  • *NEW! HPV vaccine has been extended to all females up to the age of 26 years

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.