Traditional Plan - Old Mutual Staff Medical Aid Fund

Day-to-day Benefits

PMSA is used to pay for day-to-day medical services such as GPs, dentistry, acute medicine etc.
Paid from Personal Medical Savings Account at cost; then from PCB at 1 x MSR.
Unused PMSA carries over to the new benefit year and becomes accumulated savings.
Primary Care Benefit (PCB) is used similar to the PMSA when you’ve run out of PMSA.
Any unused PCB does not carry over.
PMSA can be used to purchase vitamins.
Accumulated Savings can be used for frail care from registered frail care facilities.
Members are required to consult with their GP first, to obtain a referral to a specialist.
Specialist claims without a referral will have 25% co-payment levied on the total specialist bill. This will exclude consultations relating to your registered PMB Chronic Conditions as per your PMB treatment plan and the following practice types listed below:Ophthalmologist; Dermatologist (for lives >35 years); Psychiatrist; Gynaecologist; Oncologist; Haematologist; Urologist (for lives > 40 years) and Paediatrician (for lives < 2 years). Payable at MSR or cost, whichever is lesser. Subject to PMSA and PCB.

Email for specialist referral and authorisation: spec.auth@omsmaf.co.za

Managed Care Benefits

Members have access to treatment plans and chronic medication for the medical management of their PMB conditions.

- Chronic Medicine Benefits.
- Mental Health Programme.
- Back and Neck Rehabilitation Programme.
- Oncology Programme.
- HIV/AIDS Management Programme.
- Active Disease Risk Management Programme.
- Mother and Baby Care Programme.

Hospital Benefits

Unlimited overall annual limit (subject to certain sub-limits)

Basic pathology: Subject to the Overall Annual Limit and Managed Care protocols.
Basic radiology: Subject to the Overall Annual Limit and Managed Care protocols.
Physiotherapy: Subject to the Overall Annual Limit and Managed Care protocols.
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 from Risk and not from your Day-to-Day Benefits.)

Medical Appliance Sub-limit of R12 700 per family. (Comprehensive, paid at 1 x MSR).
Foot Orthotics R5 760 per family (subject to overall limit).
Hearing Aids R22 700 per ear per beneficiary, subject to a co-payment of 10%. Benefit is available every 3 years for those under the age of 7 and those over 85 years and every 5 years for beneficiaries between the ages of 7 and 84 years.
Specialised Radiology R23 100 per family, with a co-payment of R1 500 per authorisation (non-PMBs)
Ultrasound scans (non-pregnancy) R9 440 per family.
Refractive Procedures MSR or cost, whichever is the lesser, up to a sub-limit of R20 300 per beneficiary.
Maternity Benefits refer to member guide for full benefit structure.
Dental implants R19 200 per family. A R1 500 co-payment will apply for all Fund-approved dental admissions to hospital.

Maternity Benefits

All pregnant beneficiaries have to register on the Mother and Baby Care Programme.
Antenatal classes: R2 650 per family per benefit year.
Antenatal visits: 12 visits per pregnancy, paid at MSR.
Ultrasound scans: Two 2-D scans per beneficiary.
Out-of-hospital pathology tests (pregnancy): R4 110 per family per benefit year: Refer to the Maternity Booklet on the website www.omsmaf.co.za for list of specific pregnancy related blood tests.
Antenatal vitamins: 100% of MMAP or Medicine Price, subject to prescription from an approved list and included in the Hospital Benefit. Please refer to the Maternity Booklet on the website www.omsmaf.co.za for list of vitamins.
A Doula (birthing coach): as part of the in-hospital maternity benefit, subject to a limit of R3 160 per pregnancy for delivery only.
Lactation Nurse Consultation : Out-of-Hospital Benefit to access a lactation nurse for a maximum of 8 sessions within 2 weeks of discharge from hospital, paid at MSR to help establish breast feeding.

Chronic Benefits

Subject to Enhanced Formulary

R16 200 per family

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 950 per beneficiary. R2 470 sub-limit for oral contraceptives. HPV vaccine has been extended to all females up to the age of 26 years.
Non-pharmacy based benefits: 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 will be funded.
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 performed by a Radiology laboratory, similar to a Mammogram, no additional GP or Specialist consultations will be covered other than one GP or Specialist Wellness Consultation per beneficiary, per annum.
*NEW! Wellness Maximiser Benefit – 2 virtual GP consultations (incl. the cost of acute medicine) per family and unlimited nurse advice online chats via the Universal.one App. Only available once all adult beneficiaries have completed all their Pharmacy-based Wellness Screening tests and available Day-to-Day benefits being depleted.

What are my monthly contributions?

Traditional and Traditional SELECT Plan

Offers Comprehensive Benefits for a variety of Healthcare Services including Hospital Benefits, Day-to-day, a wide-range of Chronic conditions, an extensive Supplementary Benefit and Wellness Screenings.

Complete cover at a lower cost
Get all the cover of the Traditional Plan for a more cost-effective monthly contribution based on a restriction to select hospital providers.

Ready to make a decision?

Download and email your completed form to
membership@omsmaf.co.za or call 0860 100 076 for assistance.

Download