2018 BENEFIT BROCHURE - TFG Medical Aid Scheme
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BENEFIT BROCHURE 2018
Value offering of
TFG Medical Aid Scheme (TFGMAS)
This brochure provides you with the most important information and tools you need
to know about your health plan and how to make the most of your cover.
Thank you for giving us the opportunity to look after your
healthcare cover needs. You can have peace of mind that
Our Scheme Rules are available
TFGMAS places you first with a focus on comprehensive
benefits, value for money and services to improve the This brochure is a summary of the benefits and
quality of care available to you. features of TFGMAS, pending formal approval
from the Council for Medical Schemes (CMS).
As a TFGMAS member, you have access to excellent
healthcare cover. This brochure does not overrule the registered
Rules of the Scheme. If you want to refer to the
We have designed this guide to provide you with a
full set of Rules, please visit our website at
summary of information on how to get the most out of
www.tfgmedicalaidscheme.co.za or email
your medical scheme. You’ll find online tools that help you
compliance@discovery.co.za.
choose full cover options for specialists, chronic medicine
and GP consultations. The Rules and benefits explained in this guide
apply to the main member and registered
We are here to help and guide you in making the best
dependants. If there is anything in this brochure
choices when it comes to your healthcare.
you need explained further, please email
service@discovery.co.za and we will answer
your questions.
Glossary 01
Frequently asked questions 02
Scheme website 04
The application of waiting periods and late joiner penalties 05
Summary of new benefits 07
TFG Medical Aid Scheme plans 08
Cover for medical emergencies 10
Hospital benefit 1 1
Prescribed Minimum Benefits (PMB) 12
Cover for healthcare professionals 12
Cover for chronic conditions 13
Cover for cancer treatment 15
Your benefits for 2018 16
Contents
Contributions for 2018 22
How to access your health plan using
the Discovery app and TFGMAS website 23
How to use the MaPS tool on our website 24
How to submit claims 25
How to get the most out of your claim statement 26
General exclusions 27
Keep your personal details up to date 28
Quick contact references 28
E
x Gratia Policy 29
Complaints and disputes 29
Glossary
Co-payment Medical emergencies
This is the amount you may be asked to pay in addition to This is a condition that develops quickly, or occurs from
what we pay to cover your medical expenses. For example, an accident, and you need immediate medical treatment
if you see a non-network doctor who charges more than or an operation. In a medical emergency, your life could be
the TFG Medical Aid Scheme Rate, TFGMAS will pay you in danger if you are not treated, or you could lose a limb
for the visit at the TFGMAS Scheme Rate and you will have or organ. Not all urgent medical treatment falls within the
to pay the extra amount from your own pocket. Another definition of PMB. If you or any members of your family
example is if you see an optician who is not on the visit an after hours emergency facility at the hospital, it
Designated Service Provider list of TFGMAS. The Scheme will only be considered as an emergency and covered as
will then only pay your account at the network rate and a PMB if the treatment received aligns with the definition
you will have to pay the difference from your own pocket of PMB. Remember not all treatment received at casualty
units are PMB.
Designated Service Provider (DSP)
Preauthorisation
This is a doctor, specialist or other healthcare provider
TFGMAS has reached an agreement with about payment and You have to let us know if you plan to be admitted
rates for the purpose of Prescribed Minimum Benefits (PMB). to hospital. Please phone us on 0860 123 077 for
preauthorisation, so we can confirm your membership
When you use the services of a designated service and available benefits. Without preauthorisation, you may
provider, we pay the provider directly at the TFGMAS have to make a co-payment of R2 000 for each admission.
Rate. We pay participating specialists at the Premier, Preauthorisation is not a guarantee of payment as it
Classic Direct or TFGMAS Rate for claims. We also pay only aims to confirm that the treatment to be received
participating general practitioners at the contracted GP in hospital is clinically appropriate and aligned with the
rate for all consultations. You will not have to pay extra benefits available. We advise members to talk to their
from your own pocket for providers who participate in treating doctor so they know whether or not they will
the Premier and TFGMAS network arrangements, but may be responsible for out of pocket expenses, when they
have a co-payment for out-of-hospital visits to specialists preauthorise their treatment.
on the Classic Direct Payment Arrangement.
There are some procedures or treatments your doctor can
do in their rooms. For these procedures you also have to
Healthcare professionals
get preauthorisation. Examples of these are endoscopies
Healthcare professionals who we have a payment and scans.
arrangement with. TFGMAS has agreed rates with certain
general practitioners and specialists so you can get full If you are admitted to hospital in an emergency, TFGMAS
cover and reduce the risk of co-payments. TFGMAS pays must be notified as soon as possible so that we can
these doctors and specialists directly at these agreed authorise payment of your medical expenses. We use
rates. Please also see an article on page 24 of how to certain clinical policies and protocols when we decide
search and find these providers using the MAPS Tool. whether to approve hospital admissions. These give
us guidance about what is expected to happen when
Hospital Benefit someone is treated for a specific condition. They are based
on scientific evidence and research.
These claims are paid from the Risk Benefit by TFGMAS.
The Hospital Benefit covers your expenses for serious
illness and high-cost care while you are in hospital, if Scheme/TFGMAS Rate
we have confirmed you have cover for your admission. This is the Rate at which we pay for your medical claims.
Examples of expenses covered are theatre and ward fees, The Scheme Rate is based on the Discovery Health Rate or
X-rays, blood tests and the medicine you use while you are on specific rates that we negotiate with healthcare service
in hospital. providers. In some instances cover is at 80% of Scheme
Rate and in other instances at 100% of the Scheme Rate or
Managed benefits negotiated contracted fees. If your doctor charges more
than the Scheme Rate or negotiated fees, we will pay
These benefits are managed to facilitate appropriateness
available benefits to you at the Scheme Rate or negotiated
and cost-effectiveness of relevant health services within
rates and you will have to pay the healthcare provider.
the constraints of what is affordable, using rules-based and
Please consult your Benefit under the ‘Rate’ column to
clinical management-based programmes
know when are claims paid at 100% of Scheme Rate and
when at 80% of Scheme Rate.
01
Frequently asked
Questions 01 Do I need to get a
preauthorisation number
for specialised dentistry?
For more FAQ please go to When you need to receive dental services in hospital,
www.tfgmedicalaidscheme.co.za you will need to contact us by calling 0860 123 077
to preauthorise your hospital admission, at least
48 hours before you go into hospital. It is always
better to contact the contact centre and to verify
your benefits to determine whether you will have
a co-payment and whether or not a particular
treatment will be covered before obtaining services
for specialised dentistry.
02 How do I find the details
of the doctors in TFGMAS
network?
Go to our website www.tfgmedicalaidscheme.co.za
and log in with your username and password.
If you are looking for the nearest doctor, go to
‘Hospital and doctor visits’ and click on ‘Find
a healthcare professional’. You can search by
healthcare professional name or by area.
See page 24 for more information on how to
navigate the website to search for a healthcare
professional that is in the TFGMAS network.
03 How do I determine whether
I’m entitled to a subsidy on
my monthly contribution
amount?
Your HR Manager will be able to assist and provide
further information to you.
04 What is a network provider
and why should I use one?
We negotiate rates with healthcare providers on
your behalf and make sure that the providers follow
certain rules. We call healthcare providers we have
a payment agreement with designated service
providers (DSPs) or network providers.
When you visit a network provider, we pay their
claims in full from your available day-to-day benefits.
We cover the costs of diagnosing and treating
Prescribed Minimum Benefit conditions in full if you
visit a network provider. If you use a non-network
provider, you have to pay the difference between
what we pay and what they charge yourself.
To find a network provider, log in to
www.tfgmedicalaidscheme.co.za and click on
Find a healthcare provider.
02
05 What do I do when a claim or
query is not resolved to my 09 Will I have a waiting period when
joining the Scheme?
satisfaction?
Depending on whether there was a break in your membership
Please see page 29 for more information regarding the with a previous medical scheme, or when you were
complaints and disputes procedure of the Scheme. employed at TFG and when you decided to join the Scheme,
a waiting period may be applicable. Please consult from
page 5 of this Benefit Brochure for more information in
06 What happens if my contributions
or claims debt due to the Scheme
respect of waiting periods and when it
may be applied. You can also call the contact centre
on 0860 123 077 to obtain more information.
is not paid?
When obtaining services from a service provider, a service
contract is entered into between yourself and the service
provider and you will remain liable for any amounts due to 10 What does late-joiner penalty
(LJP) mean and why was a LJP
the service provider until it is either settled by the Scheme applied when I joined the Scheme?
on your behalf, or paid by yourself. Please follow up on
payment reminders received from service providers and Late joiner means an applicant or the adult dependant
amounts that remain outstanding and do not ignore any of an applicant who, at the date of application for
letters of demand received from healthcare providers. membership, is 35 years old or older and has not been
Call the contact centre at 0860 123 077 and find out a member or a dependant of a member of any medical
the reasons for non-payment, determine whether you are scheme for two years immediately before applying for
responsible for any co-payments and ensure that your membership. This definition excludes any beneficiary who
accounts are settled and credits are processed by the enjoyed coverage with one or more medical schemes
healthcare service provider, where necessary. preceding 1 April 2001, without a break in coverage
exceeding three consecutive months since 1 April 2001.
07 Can I cancel my membership with
the Scheme, while an employee
11 How do I access my claims
statement?
of TFG?
You can obtain your claims statement as follows:
Yes, only if you can prove that you are joining a different
medical scheme or your spouse’s scheme if you are •
After a claim submission, an email will be sent to the
employed per the employer grading system between email address registered with the Scheme to confirm
grade 1-9. Please enquire with your HR Manager about the receipt and the amounts processed and paid
the implications in respect of future employer subsidies
•
Download the Discovery app and use it to request a
that may no longer be available to you if you choose
copy of your claims statement
to re-instate your membership with the Scheme at a
future date or time. •
You can also view your claims history using the
Discovery app
08 Does my contribution increase when •
Claim statements may also be viewed and downloaded
via the website, www.tfgmedicalaidscheme.co.za
my salary increases each year?
Contributions are reviewed annually. For the 2018 benefit
year, the trustees have changes to the contribution structure.
Please refer to the Contribution Table available in this Benefit
12 Who do I ask about the formulary
applied to chronic conditions?
Brochure to determine your contribution payable per your
You need to contact the Scheme at 0860 123 077.
salary band and plan of choice.
For more details please visit www.tfgmedicalaidscheme.co.za
More information is also provided on page 13 of this guide.
13 What do you mean when you say
you pay at the Scheme Rate?
ownload the Discovery app
D
We use ‘Scheme Rate’ as an umbrella term for all the rates
and use it to request a copy we’ve negotiated with network providers. For example, if we
of your claims statement say we pay for a visit to the GP at the Scheme Rate, we pay
the GP at the rate we’ve negotiated for GP consultations.
03
Find it all on
TFG Medical
Aid Scheme
Website
You can find the application forms you
need on TFG Medical Aid Scheme website,
www.tfgmedicalaidscheme.co.za
Simply go online and More information
choose the right application
at your fingertips
form to suit your needs.
You can download the There is also information
application form or simply available on the plans
view it as a PDF. we offer, your benefits
and cover, our wellness
On the website, you can
programmes, claims and
get application forms
loads more.
to join TFG Medical Aid
Scheme, add dependants If you still can’t find what
or change registrations, you’re looking for, please
add to or manage your give us a call on
beneficiaries, as well 0860 123 077. All our
as forms to manage other contact details
other aspects of your are also available on
membership. the website.
04
TFGMAS and the application of
Waiting Periods (WP) and
Late-Joiner Penalties (LJP)
The Medical Schemes Act 131 OF 1998, 1. Waiting periods (WP)
as amended, allows medical aid schemes to 1.1 Category A
impose the following waiting periods and late Applicants that have had no previous medical cover or
joiner penalties on members applying to join have allowed a break of more than 90 days in membership
a medical aid scheme: since resigning from their previous medical aid scheme.
1.2 Category B
• A general waiting period no longer than three months Applicants who have had less than two years’ cover
• A condition-specific waiting period no longer than and applied to join TFGMAS less than 90 days after
12 months resigning from their previous medical aid scheme.
• A late-joiner penalty. 1.3 Category C
TFGMAS applies legislation when members and their Applicants who have had two years’ or more cover
dependants join the Scheme by dividing applicants and applied for cover less than 90 days since the date
into three groups for underwriting, as follows: of resigning from their previous medical aid scheme.
The applicable waiting periods therefore depend
on the category the members/dependants fall in.
The below flowchart sets out for illustrative purposes, the categories, per legislation, that are
used in determining whether a waiting period and late joiner penalty (LJP) may be applied.
It is important to note that TFGMAS don’t apply waiting periods on new employees who
have not been members of a medical scheme in the past when applying for employment and
membership of TFGMAS at the same time.
Does the applicant have previous medical cover with a previous medical aid scheme?
No Yes
New employees to Is there a break of > 90 days in membership?
the group may
qualify for exception
Yes No
from these waiting
periods. For more
information call Does the applicant have < 2 years’ cover
us on 0860 123 077 with the previous medical scheme?
Yes No
Category A Category B Category C
05
2. Late-joiner penalties
The Council for Medical Schemes defines a late joiner The penalty is only calculated on the member or
as follows: dependant’s portion of the contribution. The employer
does not subsidise the LJP.
‘A late joiner is an applicant or the adult dependant
of an applicant who at the date of application for The penalty will apply for the duration of the membership.
membership of admission as a dependant, as the case
may be, is 35 years of age or older, but excludes any 2.1 PENALTY BANDS
beneficiary who enjoyed coverage with one or more Penalty bands Maximum penalty
medical schemes preceding 1 April 2001, without a break
in coverage exceeding three consecutive months since 1 – 4 uncovered years 5%
1 April 2001.’
5 – 14 uncovered years 25%
What this means 15 – 24 uncovered years 50%
Late-joiner penalties can be applied where: 25+ uncovered years 75%
•
An applicant, or dependant of an applicant is aged 2.2 CALCULATION OF UNCOVERED YEARS
35 years or older at the time of registration and
Age of member minus (35 + creditable coverage)
•
The date of employment and date of registrations = uncovered years.
is not the same and
For instance, if the applicant is 58 years old on the date of
•
Proof of membership with a medical aid scheme registration and belonged to another medical aid scheme
on 1 April 2001 cannot be provided and for 12 years (membership certificate attached as proof),
•
Date of joining the Scheme is not within 90 days of the following LJP penalty band would apply:
resigning from the previous medical aid scheme and/or 58 – (35+12) = 11 uncovered years = 25% LJP
•
More than 90 days’ consecutive break in coverage
To ensure fairness and consistency, TFGMAS Board
between medical aid schemes exist.
of Trustees approved an Underwriting and Eligibility
The late-joiner penalty could be imposed on the Policy. This document is used by the administrator when
contributions payable. The penalty does not affect receiving applications for processing.
benefits, but will increase contributions for the duration
of the membership.
06
A summary of new benefits introduced
for 2018 and how your benefits work
Understanding the benefits on your chosen plan
The Hospital Benefit covers you if you are admitted a list of medical conditions and treatments, even if your
to hospital and TFG Medical Aid Scheme has preauthorised health plan benefits have run out. These benefits include
admission rules to adhere to before you will be admitted. cover for a list of conditions, including the 26 Prescribed
Minimum Benefit (PMB) Chronic Disease List (CDL)
You have extensive cover for a list of certain chronic
conditions and HIV and AIDS.
conditions and cover for cancer, and HIV and AIDS.
Medical aid schemes must provide cover for the
We pay your day-to-day expenses from the Primary
diagnosis, treatment and cost of ongoing care for
Care Benefit which covers you for Primary Care
these conditions according to the Scheme’s Rules
Consultations such as GPs, specialists and basic dentistry
and guidelines.
visits and benefits. Please consult the Primary Care
Consultations section under the ‘Your Benefits for 2018’. To find out how you can access your Prescribed Minimum
Benefits, go to www.tfgmedicalaidscheme.co.za
According to the Prescribed Minimum Benefits (PMB),
or contact us for more information.
you have the right to a guaranteed level of cover for
New benefits introduced by the Scheme for 2018:
1.
ADDITIONAL PREVENTION AND SCREENING 3. VACUUM ASSISTED BREAST BIOPSY (VABB)
HEALTH CHECKS
Applies to: Plan A and B
Applies to: Plan A and B A negotiated tariff will be funded for one procedure
The Screening and Prevention Benefit covers per year to members who requires VABB with effect
certain tests such as blood glucose, blood pressure, from 1 January 2018.
cholesterol, body mass index and HIV screening at
VABB is not clinically appropriate for the
one of our wellness providers.
investigation of all breast lumps and will therefore
Members with high readings in the random glucose be managed through the Discovery Health Medical
or basic cholesterol tests will also be given the more Review Team (MRT) and only those applications
clinically robust HbA1c and Lipogram per high risk regarded as clinically appropriate will qualify for
beneficiary. funding up to the negotiated tariff for the procedure
The tests can be obtained at your nearest network to be done by preferred/designated service providers.
pharmacy or during a wellness day event. Tests
Services provided and cost to be incurred above
done at a pathology laboratory will continue to be
the negotiated tariff for one procedure per breast
funded from your available day-to-day benefits.
per year and any other related costs to be incurred
The prevention and screening health check is an
in addition will fund from members’ available day-to-
enhancement to this Risk benefit.
day benefits, as may be appropriate and necessary.
Where these day-to-day benefit limits are reached,
2. LIMIT DIFFERENTIATIONS
the balance outstanding will remain payable by
Applies to: Plan A and B
the member.
To achieve increased differentiation between Plan A
and B and to ensure that benefits are aligned with
industry recommended benefit limits, some limits
were increased with more or slightly less than the
average 5.5% that was applied in most instances.
For more information please turn to page 19 in this
Benefit Brochure.
07TFG Medical Aid Scheme plans
TFG Medical Aid Scheme (TFGMAS) offers two plans to its members that are both affordable, yet
differentiated, and this provides members with an option of low or high cover. Below is an easy
comparison guide to use to compare the benefits provided on Plan A versus the benefits provided
on Plan B for 2018.
PLAN A PLAN B
Overall annual limit R600 000 per family per year R2 000 000 per family per year
Hospital Cover
Cover of hospital costs and Up to Overall Annual Limit. Up to Overall Annual Limit.
other accounts, like accounts Where PMB level of care is Where PMB level of care is
from your admitting doctor, applicable payments will applicable payments will
anaesthetist or any approved continue through the Overall continue through the Overall
health care expenses, while Annual Limit. Annual Limit.
you are in hospital
Only covered for Prescribed Up to an amount of R25 000 per
Minimum Benefits (PMB) beneficiary with an overall limit
Chronic Medicine
Clinical guidelines, protocols, of R69 000 per family per year,
The scheme pays for an
pre-approval and authorisation thereafter Prescribed Minimum
approved chronic medicine
required. An additional 4 Benefits only. An additional 4
list of conditions, subject
consultations per beneficiary consultations per beneficiary
to an applicable Chronic
are available with a GP where are available with a GP where
Drug Amount at 100% of the
a member is registered on the a member is registered on the
Scheme Rate
Chronic Illness Benefit (CIB) and Chronic Illness Benefit (CIB) and
the condition is PMB related. the condition is PMB related.
Specialists: 100% of Scheme
Rate at non-network providers
Primary care benefits and 100% of the Scheme or
All: 80% of Scheme Rate at non-
Consultations and visits to negotiated rate at network
network providers and 100% of
GP’s, specialists, registered providers.
network or negotiated rate at
private nurse practitioners and Other: 80% of Scheme Rate at
network providers
associated health services. non-network providers and 100%
of the Scheme or negotiated rate
at network providers
Oncology Limited amount per beneficiary Limited amount per beneficiary
Cover to members diagnosed per rolling 12 month period per rolling 12 month period
with cancer over a rolling 12 of R200 000. Benefit is paid of R550 000. Benefit is paid
month period and provided at 100% of Scheme Rate until at 100% of Scheme Rate until
to members from date of this benefit limit is reached. this benefit limit is reached.
diagnosis and registration on Thereafter it is paid at 80% of Thereafter it is paid at 80%
the Oncology programme. Scheme Rate. of Scheme Rate.
100% of Scheme Rate for one 100% of Scheme Rate for one
comprehensive consultation, comprehensive consultation,
lens and frames per beneficiary, lens and frames per beneficiary,
subject to limits subject to limits
Optical
A biennial benefit available Consultation R650 Consultation R650
every second benefit year Single lens R400 OR Single lens R400 OR
depending on date of first Bifocal lens R900 OR Bifocal lens R900 OR
claim received Multifocal lens R1 700 OR Multifocal lens R1 700 OR
Frame R750 Frame R950
Contact lenses R2 750 Contact lenses R3 000
(Alternative to glasses) (Alternative to glasses)
08PLAN A PLAN B
In addition to the Primary
In addition to the Primary
care benefit GP consultations,
care benefit GP consultations,
Pregnancy and Maternity 4 consultations at a GP or
2 consultations at a GP per
Consultations gynaecologist per pregnant
pregnant beneficiary per
beneficiary per pregnancy are
pregnancy are provided
provided
Children’s Screening Benefit
Screening Benefits for children aged 2 to 18 available from the
1 BMI, 1 Hearing, 1 Dental check-
Prevention & Screening Risk Benefit from the overall annual limit.
up, 1 online milestone tracking
PrEP (Pre Exposure Funding of PrEP medication will be made available to members
Prophylaxis) where authorised and pre-approved by Discovery Managed Care
You may only change from one plan to The summary of benefits does not
another at the end of each year, with overrule the Rules of the Scheme.
effect from 1 January the following To refer to the Rules or for more
year. In terms of the Rules of the information visit the HR portal or
Scheme, you may not change your www.tfgmedicalaidscheme.co.za
plan during the year.
09Cover for
medical emergencies
What is a medical emergency? COVER WHEN GOING TO CASUALTY
A medical emergency is the sudden and unexpected If you are admitted to hospital from casualty, we will cover
onset of a health condition that needs immediate medical the costs of the casualty visit from your Hospital Benefit,
or surgical treatment, where failure to provide this as long as we preauthorise your hospital admission.
treatment would result in: If you go to a casualty or emergency room and you
•
Serious impairment to bodily functions are not admitted to hospital, TFGMAS will pay the
costs from your available Primary Care Benefit Limits.
•
Serious dysfunction of a bodily organ or part
In certain instances we may not cover the facility fee
•
The person’s life being placed in serious jeopardy. charged by same institutions.
Cover for medical emergencies COVER UNDER THE PRESCRIBED MINIMUM
in South Africa BENEFITS
COVER WHEN GOING TO HOSPITAL In an emergency, we will cover you in full at any provider
until your condition is stable. You may have a co-payment
In an emergency, go straight to hospital. If you need
once your condition is stable and you receive treatment
medically equipped transport, call 0860 999 911. This
from a non-designated service provider who charges
line is managed by highly qualified emergency personnel
more than the Scheme Rate. Please remember that even
who will send air or road emergency evacuation transport
though you or your doctor may consider your treatment
to you, depending on which is most appropriate.
to be an emergency, it may not be classified as an
It is important that you, a loved one or the hospital
emergency under the Prescribed Minimum Benefits.
let us know about your admission as soon as possible,
so that we can advise you on how you will be covered COVER OUTSIDE SOUTH AFRICA
for the treatment you receive.
Cover outside South Africa is limited to territories within
COVER FOR HIV MEDICINES – PRE-EXPOSURE the Rand monetary area and will be covered according
(PREP) AND POST-EXPOSURE PROPHYLAXES (PEP) to the Scheme Rules. Travellers should always ensure
that they obtain additional medical insurance cover when
If you need HIV medicine to prevent HIV infection, mother-
travelling outside the borders of South Africa.
to-child transmission, occupational or traumatic exposure
to HIV, including sexual assault, call us immediately
on 0860 123 077. Treatment must start within 72 hours
of exposure subject to approval.
10Hospital
Accounts from your doctor and other
healthcare services
Your doctor or treating healthcare professional’s accounts
benefit
are separate from the hospital account and are called
related accounts. Related accounts include any account
other than the hospital account. Examples of related
accounts are the account from the admitting doctor,
anaesthetist and any approved healthcare expenses,
like radiology or pathology, that you incur during your
hospital stay. Refer to the section ‘Cover for healthcare
professionals’, found on page 15 of this Benefit Brochure
for more information. Please contact us to preauthorise
your benefits before you receive treatment or extend your
hospital stay.
Before you go to hospital for any
planned procedure, you must:
•
See your doctor who will decide if it is necessary
for you to be admitted
•
Make sure you know how the account from your
admitting doctor will be covered
•
Choose which hospital you want to be admitted to
by using the MAPS tool available
•
Find out how we cover other healthcare professionals,
for example, your anaesthetist
Call us on 0860 123 077 to preauthorise your hospital
•
admission at least 48 hours before admission. We will
give you information that is relevant to how we will pay
for your hospital stay. A co-payment of R2 000 will be
levied on the hospital account if preauthorisation is
not obtained, except in an emergency
•
Please refer to the cover for medical emergencies
Your approved hospital admission is subject for more information.
to your available cover on your chosen plan.
You can go to any private hospital for Cover is subject to the Scheme Rules
emergency and planned admissions. We pay medically appropriate claims. Your cover is subject
You can receive full cover for Prescribed to our Scheme Rules, funding guidelines and clinical rules.
Minimum Benefit (PMB) treatment and care. There are some expenses that you may incur while you
are in hospital that your Hospital Benefit does not cover,
for example, private ward costs. Familiarise yourself with
Important information about your
the Scheme Rate applicable per your chosen Plan and
hospital cover the possible co-payments where you are being serviced
We cover the hospital cost and other accounts, such as by a provider who is not on the network or contracted
accounts from your admitting doctor, anaesthetist or any with the Scheme. Please be aware that certain procedures,
approved healthcare expenses, while you are in hospital. medicines or new technologies need separate approval
while you are in hospital.
Limits, clinical guidelines and policies apply to some
healthcare services and procedures in hospital.
Please discuss this with your
How we pay the hospital account doctor or the hospital. Use our
online MaPS Advisor, available on
We pay the hospital account (the ward and theatre fees)
at the rate agreed with the hospital. You have cover for www.tfgmedicalaidscheme.co.za
a general ward, not a private ward. to find a provider in the network.
11Prescribed Minimum Benefits (PMB)
Cover for Prescribed Minimum Benefits are rules that apply:
Prescribed Minimum Benefits is a set of minimum benefits •
Your medical condition must qualify for cover and
that, by law, must be provided to all medical scheme be part of the list of defined Prescribed Minimum
members. The cover it gives includes the diagnosis, Benefit conditions
treatment and cost of ongoing care for a list of conditions. •
The treatment needed must match the treatments
The list of conditions is defined in the Medical Schemes offered in the defined benefits
Act 131 of 1998.
•
If you are outside of the benefit limit you must use
The Prescribed Minimum Benefits make provision for the designated service providers in the network. This does
cover of the diagnosis, treatment and ongoing care of: not apply in life-threatening emergencies, however,
•
270 diagnoses and their associated treatment even in these cases, where appropriate, and according
•
27 chronic conditions to the Rules of the Scheme, you may be transferred to
a designated service provider, otherwise a co-payment
•
Emergency conditions.
will be levied. You will be responsible for the difference
In most cases, TFG Medical Aid Scheme plans offer between what we pay and the actual cost of your
benefits that cover far more than the Prescribed Minimum treatment, where applicable.
Benefits. To access Prescribed Minimum Benefits, there
Cover for shortfalls in your benefit cover when
it’s time to claim. We’ve provided
Cover to give you peace of
mind
healthcare you with this choice by working
together with our administrator, We offer you the choice to have
Discovery Health, and participating full cover for hospitalisation,
professionals healthcare professionals, to create specialists in hospital, chronic
medicine and GP consultations.
benefit structures and payment
arrangements that reduce gaps We pay healthcare providers in our
Get wise and use providers in in your benefit cover. Providers in network directly, saving you the
our network our network are providers we have hassle. In hospital we cover you up
an agreement with to charge you no to 100% of the Scheme Rate. We
We at TFG Medical Aid Scheme
more than the Scheme Rate. When cover GPs who are on our network at
believe in comprehensive healthcare.
you use these healthcare providers, 100% of the Network Rate.
That’s why we want to ensure that
you don’t have shortfalls in your you should not have shortfalls in
benefit cover and no out-of-pocket
How to find your nearest
benefit cover. We do this by offering
expenses, subject to your available provider to maximise
you the choice of using healthcare
providers in our network. benefit and annual limits. your cover
Different cover in terms of the You can use our Medical and
Cover for specialists who are percentage of Scheme Rate Providers Search (MaPS) on
on our network and non- applies, depending on whether you the Scheme website to find a
network specialists are a Plan A or Plan B member. For healthcare professional who we
Visiting specialists in our network more information please consult have an agreement with.
will minimise your exposure against this Benefit Brochure from page 19.
12Cover for chronic conditions
You have extensive cover for chronic conditions, HIV and AIDS and cancer.
Chronic Illness Benefit (CIB) • Parkinson’s disease
The Chronic Illness Benefit (CIB) covers approved medicine • Rheumatoid arthritis
for a list of 26 Prescribed Minimum Benefit (PMB) Chronic • Schizophrenia
Disease List (CDL) conditions. We will pay your approved
• Systemic lupus erythematosis
chronic medicine in full if it is on our medicine list
(formulary). If your approved chronic medicine is not on • Ulcerative colitis
our medicine list, we will pay your chronic medicine up to
a set monthly amount (Chronic Drug Amount) for each Additional Chronic Cover
medicine category. You will be responsible to pay any An Additional Disease List (ADL) on Plan B provides
shortfall yourself. members with an additional list of chronic conditions
If you use a combination of medicine in the same covered on this Plan.
medicine category, where one medicine is on the On Plan B, you have cover for a defined list of additional
medicine list and the other is not, we will pay for the chronic conditions. There is no medicine list (formulary) for
medicines up to the one monthly Chronic Drug Amount these conditions. We pay approved medicines for these
(CDA) for that medicine category. conditions up to the monthly Chronic Drug Amount (CDA):
CDL PMB CONDITIONS COVERED ON BOTH • Ankylosing spondylitis
PLAN TYPES. • Attention Deficit Hyperactivity Disorder (ADHD)
The cover for medicine is subject to the Scheme medicine • Behcet’s disease
list (formulary) or the monthly CDA. • Cystic fibrosis
• Addison’s disease • Delusional disorder
• Asthma • Dermatopolymyositis
• Bipolar mood disorder • Generalised anxiety disorder
• Bronchiectasis • Gastro-oesophageal reflux disease
• Cardiac failure • Gout
• Cardiomyopathy • Huntington’s disease
• Chronic obstructive pulmonary disease (COPD) • Isolated growth hormone deficiency in children
• Chronic renal disease • Major depression
• Coronary artery disease • Motor neuron disease
• Crohn’s disease • Muscular dystrophy and other inherited myopathies
• Diabetes insipidus • Myasthenia gravis
• Diabetes mellitus type 1 • Obsessive compulsive disorder
• Diabetes mellitus type 2 • Osteoporosis
• Dysrhythmia • Paget’s disease
• Epilepsy • Panic disorder
• Glaucoma • Polyarteritis nodosa
• Haemophilia • Post-traumatic stress disorder
• HIV and AIDS • Psoriatic arthritis
• Hyperlipidaemia • Pulmonary interstitial fibrosis
• Hypertension • Sjogren’s syndrome
• Hypothyroidism • Systemic sclerosis
• Multiple sclerosis • Wegener’s granulomatosis
13We need to approve your application If you use a pharmacy outside of the Scheme’s
Pharmacy Network, you may have a co-payment if the
We need to approve your application before we cover
pharmacy charges you a dispensing fee that is higher
your condition and medicine from the Chronic Illness
than that agreed with network pharmacies. Use our
Benefit (CIB).
online MaPS Advisor at www.tfgmedicalaidscheme.co.za
To apply, contact us to get an application form or go to to find a network pharmacy.
www.tfgmedicalaidscheme.co.za. Complete the relevant
Please note that the Scheme’s approved Medicine List
application form with your doctor and send it to us.
and Chronic Drug Amounts are updated from time to
We will send you a letter detailing the cover available
time based on regulatory changes and continued
to you.
clinical appropriateness.
For a condition to be covered from the Chronic Illness
The Scheme Medicine Rate Benefit (CIB), there are certain benefit entry criteria that
the member needs to meet. If necessary, you or your
is the legislated price of medicine
doctor may have to give extra motivation or copies
as well as the fee for dispensing it. of certain documents to TFG Medical Aid Scheme
Use a pharmacy that has agreed to finalise your application. If you leave out any
to charge the Scheme Medicine information or do not provide the medical test results or
documents needed with the application, cover will only
Rate, to avoid co-payments on
start from the date we receive the outstanding documents
your medicine. or information.
14Your cover for
cancer treatment
The oncology benefit provides cover to members diagnosed with cancer over a rolling 12 month benefit and is provided
to members from date of diagnosis and registration on the Oncology Programme. Members therefore have access to the
oncology benefit over a 12 month period from date of diagnosis up to the benefit limits as set out below:
PLAN A PLAN B
Oncology 100% of the Scheme Rate 100% of the Scheme Rate
Limited to R200 000 per beneficiary per rolling Limited to R550 000 per beneficiary per rolling
12 month period 12 month period
Once the limit has been reached, non-PMB Once the limit has been reached, non-PMB
treatment will attract a 20% co-payment treatment will attract a 20% co-payment
We cover chemotherapy and oncology-related It is important to note that the oncology benefit is subject
medicines up to the Scheme Medicine Rate. We pay to the overall annual limit which is different on Plan A to
for treatment in hospital, consultations, radiotherapy, Plan B. Plan A overall annual limit is R600 000 per family
radiology, pathology, scopes and scans at 100% of the and R2 million per family for Plan B members.
Scheme Rate, subject to the overall annual limit. Once
You need to consult with your treating doctor to determine
the benefit limit is reached, you may be liable for a 20%
the best treatment plan for you in order to prevent co-
co-payment for non-PMB treatment and/or where non-
payments and out-of-pocket expenses.
contracted or non-designated service providers are used.
All treatment received out of hospital provided by
non-designated service providers is paid at 80% of the
Visit www.tfgmedicalaidscheme.co.za
Scheme Rate.
for a detailed explanation of
Cancer treatment that qualifies as a Prescribed Minimum
the cover offered through the
Benefit is always covered if you use a designated service
provider (DSP). Please call us to register on the Oncology Programme
Oncology Programme.
15Your benefits for 2018 16
BENEFIT RATE PLAN A PLAN B
Excess for failure to pre-authorise
A R2 000 excess will be charged if you do not get
preauthorisation from the Scheme at least 48 hours
before a hospital admission or treatment. Please note R2 000 R2 000
you may not receive payment in full even if you have obtained
preauthorisation. We can advise you on the
rate of payment before admission to hospital if you submit
the known procedure codes to us for pre-assessment.
Overall annual limit R600 000 per family per year R2 000 000 per family per year
Hospital and
hospital related
benefits
Ward and theatre fees 100% of Scheme or contracted Subject to overall annual limit Subject to overall annual limit
rate
X-rays 100% of Scheme Rate Subject to overall annual limit Subject to overall annual limit
Pathology 100% of Scheme Rate Subject to overall annual limit Subject to overall annual limit
Radiotherapy 100% of Scheme Rate Subject to overall annual limit Subject to overall annual limit
Blood transfusions 100% of cost Subject to overall annual limit Subject to overall annual limit
Organ transplants 100% of cost in state and R37 000 per live donor R37 000 per live donor
100% of Scheme Rate in
private facilities R22 500 per cadaver R22 500 per cadaver
Renal dialysis 100% of Scheme Rate R150 000 per family per year R165 000 per family per year
Vacuum assisted 100% of negotiated rate 1 procedure per breast per 1 procedure per breast per
breast biopsy beneficiary per year beneficiary per year
Psychiatric treatment 100% of Scheme Rate 21 days per beneficiary per year 21 days per beneficiary per year
Elective maxillo-facial and 100% of Scheme or Network R15 000 per family per year R 17 000 per family per year
oral surgery Rate
Internal prosthesis 100% of negotiated rate See below See below
– Total hip replacement 100% of negotiated rate R61 250 per family per year R61 250 per family per year
– Partial hip replacement 100% of negotiated rate R36 600 per family per year R36 600 per family per year
– Spinal prostheses 100% of negotiated rate R30 900 for one level R30 900 for one level
R61 900 for two or more levels R61 900 for two or more levels
– Knee replacement 100% of negotiated rate R58 050 per family per year R58 050 per family per year
– Shoulder replacement 100% of negotiated rate R50 500 per family per year R50 500 per family per year
– Cardiac stents 100% of negotiated rate R12 650 per bare metal stent R12 650 per bare metal stent
– Cardiac stents R20 200 per drug eluting stent R20 200 per drug eluting stent
– Cardiac pacemakers 100% of negotiated rate R74 500 per family per year R74 500 per family per year
– Tissue replacing 100% of negotiated rate R24 000 per family per year R24 000 per family per year
prosthesis
– Artificial limbs 100% of negotiated rate R36 600 per family per year R36 600 per family per year
– Artificial eyes 100% of negotiated rate R18 300 per family per year R18 300 per family per year
– Cardiac valves 100% of negotiated rate R30 300 per valve R30 300 per valve
– Vascular grafts 100% of negotiated rate R90 850 per family per year R90 850 per family per year
–G
eneral (Mirena subject 100% of negotiated rate R24 000 per family per year R24 000 per family per year
to approval)
Post-exposure 100% of Scheme Rate Subject to overall annual limit Subject to overall annual limit
prophylaxis
Oncology 100% of Scheme Rate at DSPs R200 000 per beneficiary per R550 000 per beneficiary per
and 80% of Scheme Rate at rolling 12 month period from date rolling 12 month period from date
non-DSPs of diagnosis. A co-payment of of diagnosis. A co-payment of
20% applies to non-PMBs once 20% applies to non-PMBs once
limit is reached limit is reached
International second 50% of cost or negotiated Pre-approval required. Applies to Pre-approval required. Applies to
opinion rates specified conditions only specified conditions only
17BENEFIT RATE PLAN A PLAN B
Home nursing 100% of Scheme Rate or R29 790 per beneficiary per year R29 790 per beneficiary per year
negotiated tariff
Step-down facilities 50% of Scheme Rate or R59 580 per beneficiary per year R59 580 per beneficiary per year
negotiated fees
Advanced Illness Benefit Available where clinically Available where clinically
(AIB) appropriate and benefit applied appropriate and benefit applied
is pre-approved is pre-approved
Chronic
medicine
Chronic medicine 100% of Scheme Medicine PMB cover only non-formulary Non-formulary medication for CDL
Rate for formulary medication medication for CDL conditions and conditions and medication for
and CDL conditions medication for ADL conditions are ADL conditions are subject to a
subject to a monthly Chronic Drug monthly Chronic Drug Amount
Amount
R25 000 per beneficiary per year
and R69 000 per family per year
Specialised
dentistry
Specialised dentistry 80% of Scheme Rate R1 900 per family per year (M) R8 600 per family per year (M)
R3 300 per family per year (M+1) R11 500 per family per year (M+1)
R4 500 per family per year (M+2) R13 800 per family per year (M+2)
R5 300 per family per year (M+3) R15 100 per family per year (M+3)
R5 800 per family per year (M+4) R16 000 per family per year (M+4)
R6 300 per family per year (M+5) R16 500 per family per year (M+5)
R6 800 per family per year (M+6) R16 900 per family per year (M+6)
R7 100 per family per year (M+7) R17 200 per family per year (M+7)
Primary care
consultations
Consultations at GPs, Plan B only: Specialists: 100% R2 100 per family per year (M) R3 700 per family per year (M)
specialists, nurse of Scheme Rate at non-
practitioners and network providers and 100% R2 600 per family per year (M+1) R5 600 per family per year (M+1)
associated health of the Scheme or negotiated
services (including virtual rate at network providers R3 000 per family per year (M+2) R7 300 per family per year (M+2)
consultations)
Other providers for Plan B R3 300 per family per year (M+3) R8 400 per family per year (M+3)
and in all instances on Plan A:
80% of Scheme Rate at non- R3 500 per family per year (M+4) R9 200 per family per year (M+4)
network providers and 100%
of the Scheme or negotiated R3 700 per family per year (M+5) R9 600 per family per year (M+5)
rate at network providers
R3 900 per family per year (M+6) R10 100 per family per year (M+6)
R4 000 per family per year (M+7) R10 200 per family per year (M+7)
Virtual paediatric Unlimited Unlimited
consultations for children
aged 0 to 14
Additional consultations 100% of the Scheme or 4 GP consultations per beneficiary 4 GP consultations per beneficiary
for PMB conditions negotiated rate at network registered on the CIB per year registered on the CIB per year
providers
Additional consultations 100% of the Scheme or 2 GP consultations per pregnant 4 GP or gynaecologist
for pregnancies negotiated rate at network beneficiary per year consultations per pregnant
providers beneficiary per year
Additional emergency 100% of the Scheme or No benefit 2 consultations per child aged
facility consultations negotiated rate at network 0 to 10
providers
Basic dentistry 80% of Scheme Rate R1 800 per family per year (M) R3 900 per family per year (M)
R2 200 per family per year (M+1) R4 700 per family per year (M+1)
R2 500 per family per year (M+2) R5 500 per family per year (M+2)
R2 800 per family per year (M+3) R6 300 per family per year (M+3)
R3 000 per family per year (M+4) R6 900 per family per year (M+4)
R3 200 per family per year (M+5) R7 300 per family per year (M+5)
R3 300 per family per year (M+6) R7 500 per family per year (M+6)
R3 400 per family per year (M+7) R7 600 per family per year (M+7)BENEFIT RATE PLAN A PLAN B
Optometry
– Consultation 100% of Scheme Rate R650 per beneficiary per R650 per beneficiary per
or cost cycle and limited to 1 visit per cycle and limited to 1 visit per
beneficiary per cycle beneficiary per cycle
– Frames 100% of Scheme Rate R750 per frame and limited to 1 R950 per frame and limited to 1
or cost frame per beneficiary per cycle frame per beneficiary per cycle
– Lenses: single vision 100% of Scheme Rate R400 per lense and limited to 1 R400 per lense and limited to 1
or cost pair per beneficiary per cycle pair per beneficiary per cycle
– Lenses: bifocal 100% of Scheme Rate R900 per lense and limited to 1 R900 per lense and limited to 1
or cost pair per beneficiary per cycle pair per beneficiary per cycle
– Lenses: Multifocal 100% of Scheme Rate R1 700 per lense and limited to 1 R1 700 per lense and limited to 1
or cost pair per beneficiary per cycle pair per beneficiary per cycle
– Contact lenses 100% of Scheme Rate R2 750 per beneficiary per cycle R3 000 per beneficiary per cycle
or cost
Benefits are provided for either Benefits are provided for either
glasses or contact lenses, but not glasses or contact lenses, but not
both. The optical benefit cycle is a both. The optical benefit cycle is a
two year period two year period
Other
Radiology and pathology 80% of Scheme Rate for R15 800 per family per year R22 700 per family per year
radiology and 100% of
Scheme Rate for pathology
Psychiatry and clinical 80% of Scheme Rate at non- R3 300 per family per year R7 400 per family per year
psychology network providers and 100%
of the negotiated rate at
network providers
Acute medicine 80% of Scheme Medicine Rate R2 700 per family per year (M) R6 100 per family per year (M)
Medicine on the preferred R3 900 per family per year (M+1) R8 900 per family per year (M+1)
medicine list funded up to
100% of Scheme Medicine R4 900 per family per year (M+2) R10 600 per family per year (M+2)
Rate for TFG Plan B only
R5 500 per family per year (M+3) R12 000 per family per year (M+3)
R5 900 per family per year (M+4) R13 000 per family per year (M+4)
R6 200 per family per year (M+5) R13 700 per family per year (M+5)
R6 400 per family per year (M+6) R14 100 per family per year (M+6)
R6 600 per family per year (M+7) R14 300 per family per year (M+7)
R 130 per claim for over-the- R180 per claim for over-the-
counter medication counter medication
Ambulance 80% of Scheme Rate at non- R3 600 per family per year. R4 200 per family per year.
network providers and 100% Unlimited if Discovery 911 is used Unlimited if Discovery 911 is used
of the Scheme or negotiated
rate at network providers
Medical appliances 80% of cost R10 200 per family per year R20 300 per family per year
Telemetric glucometer 100% of cost 1 device per beneficiary per year if obtained from contracted providers.
devices Additional devices are subject to the medical appliances benefit
Speech therapy, 80% of Scheme Rate R4 200 per family per year R6 300 per family per year
occupational therapy
and audiology
Physiotherapy and 80% of Scheme Rate R3 300 per family per year R5 500 per family per year
chiropractic therapy
Podiatry and orthoptics 80% of Scheme Rate R2 800 per family per year R4 600 per family per year
Specialised medication 100% of Scheme Rate No benefit R 230 000 per beneficiary per
year for approved medication.
A 20% copayment applies for
certain medication
19BENEFIT RATE PLAN A PLAN B
Screening and (These benefits are available at preferred provider network GPs and/or Specialists or at contracted
preventative care pharmacies administered by a nurse or at Wellness Day Events, unless otherwise stated below)
Mammogram 100% of Scheme Rate or 1 per female beneficiary per year 1 per female beneficiary per year
negotiated fees
Pap smear 100% of Scheme Rate 1 per female beneficiary per year 1 per female beneficiary per year
Prostate-specific antigen 100% of Scheme Rate 1 per male beneficiary per year 1 per male beneficiary per year
HIV test 100% of cost 12 per beneficiary per year 12 per beneficiary per year
Health checks: 100% of Scheme Rate 1 per adult beneficiary per year 1 per adult beneficiary per year
– Blood glucose
– Blood pressure
– BMI
– Cholesterol
HbA1c 100% of Scheme Rate 1 per high risk beneficiary per year 1 per high risk beneficiary per year
at a contracted pharmacy only or at a contracted pharmacy only or
at Wellness Day Events at Wellness Day Events
LDL cholesterol 100% of Scheme Rate 1 per high risk beneficiary per year 1 per high risk beneficiary per year
at a contracted pharmacy only or at a contracted pharmacy only or
at Wellness Day Events at Wellness Day Events
Flu vaccine 100% of Scheme Medicine 1 per beneficiary older than 65 1 per beneficiary older than 65
Rate per year if registered for certain per year if registered for certain
chronic conditions chronic conditions
HPV vaccine (virus types 100% of Scheme Medicine 1 per beneficiary aged 9 to 26 per 1 per beneficiary aged 9 to 26 per
16 and 18) Rate year year
Pneumococcal vaccine 100% of Scheme Medicine 1 per identified high risk 1 per identified high risk
Rate beneficiary per year beneficiary per year
Adult vaccines: 100% of Scheme Medicine – T
etanus/Diphtheria: 1 booster – T
etanus/Diphtheria: 1 booster
– Tetanus/diphteria Rate per adult beneficiary every 10 per adult beneficiary every 10
years years
– Hepatitis A
– S
hingles: 1 vaccine per – S
hingles: 1 vaccine per
– Hepatitis B beneficiary over 60 years old beneficiary over 60 years old
– Measles All other adult vaccines: All other adult vaccines:
– Mumps 1 vaccine per adult beneficiary 1 vaccine per adult beneficiary
– Rubella at risk at risk
– Chickenpox
– Shingles
– Meningococcal
Child vaccines: 100% of Scheme Medicine 1 vaccine per child beneficiary as 1 vaccine per child beneficiary as
– Polio Rate per clinical protocols per clinical protocols
– TB
– Hepatitis B
– Rotavirus
– Tetanus/dophteria
– Accellular pertusis
– Haemophilus
– Influenza Type B
– Chickenpox
– Measles
– Mumps
– Rubella
Child screening: 100% of Scheme Medicine 1 per child beneficiary aged 2 to 18 1 per child beneficiary aged 2 to 18
– BMI Rate as per clinical protocols as per clinical protocols
– Hearing test
– Dental check-up
– Online milestone
tracking
BRCA 1 & 2 gene 100% of Scheme Medicine No benefit 1 per female beneficiary per year
mutation test Rate
20Please note:
Benefits and contribution amounts are subject to Council for Medical Schemes approval. The registered rules are binding
and take precedence over the Benefit Brochure and information contained in the document.
Please refer to page 9 for more information on new benefits introduced for the Scheme from 1 January 2018.
Home nursing and step down facility benefits Maximum annual benefits referred to will be
are made available and more information can be calculated from 1 January 2018 to 31 December
obtained from the contact centre in respect of the 2018, based on the services provided during the
rate per day. The amounts reflected above are an year and will be subject to pro rata apportionment
indication of the total amounts available per year, calculated from the joining date to the end of the
which is subject to the daily limits applicable. benefit period. Benefits are not transferable from
one benefit period to another or from one category
Scheme Rate = This is the amount of money
to another. Optical benefits are not applied on a
the Scheme pays for a specific type of medical
pro rata basis. This is not an annual benefit, but a
procedure, treatment or consultation. There are,
benefit that is available over a two-year period from
however, certain healthcare professionals with
the date that you join the Scheme.
whom the Scheme has negotiated rates.
Oncology benefits are not an annual benefit
The negotiated rate replaces the Scheme Rate
but granted from date of diagnosis, following
in those instances with a Network Rate.
registration on the Oncology Programme. Benefits
are made available over a 12 month rolling period
from date of diagnosis.
21Contributions with effect from 1 April 2018
These contributions are the total amounts due to the Scheme. The member’s portion of the contributions, payable after
taking the employer’s subsidy into account, are shown in the second set of tables below.
The Contribution Tables below are before employer subsidy
Salary Band Plan A PM Adult Child
A R0 – R4 720 R1 482 R 927 R470
B R4 721 - R7 800 R1 672 R1 170 R474
C R7 801 - R15 110 R1 791 R1 307 R510
D R15 111 - R25 910 R1 947 R1 423 R560
E R25 911 - R38 590 R2 274 R1 645 R637
F R38 591+ R2 472 R1 729 R677
Salary Band Plan B PM Adult Child
A R0 - R4 720 R 2 922 R1 809 R753
B R4 721+ R3 354 R2 370 R837
All contributions shown above are 100% of the total contribution, without taking into account the 50% company subsidy
that may apply to you.
(*) Child contributions are applicable if: (**) Adult contributions are applicable if:
• A dependant is under the age of 21; •
A principal member’s dependant is over the age of 21
and does not qualify for child contribution rates as set
•
A dependant is over the age of 21, but not over the
out above.
age of 25 and a registered student at a university or
recognised college for higher education and is not self
supporting;
•
A dependant is over the age of 21, but not over the age
of 25 and is dependent upon the principal member due
to mental or physical disability.
The Contribution Tables below are after employer subsidy
These contributions are the members’ portions of the contributions, payable after taking the employer’s subsidy into account.
Salary Band Plan A PM Adult Child
A R0 – R4 720 R741 R464 R235
B R4 721 - R7 800 R836 R585 R237
C R7 801 - R15 110 R896 R654 R255
D R15 111 - R25 910 R974 R712 R280
E R25 911 - R38 590 R1 137 R823 R319
F R38 591+ R1 236 R865 R339
Salary Band Plan B PM Adult Child
A R0 - R4 720 R1 461 R905 R377
B R4 721+ R1 677 R1 185 R419
All contributions shown in these two tables are the members’ own portions after the employer’s 50% subsidy was taken into account.
If you are not entitled to a subsidy, you will have to pay the full contribution as shown in the first two tables on this page. Your human
resources department will be able to confirm whether you qualify for a medical aid subsidy.
22You can also read
