Issue link: https://www.hub.camaf.co.za/i/1512929
2024 ESSENTIAL PLUS & ESSENTIAL NETWORK 10 Benefits In Hospital Benefit and Extent of Cover Hospital Unlimited, hospital benefits - paid at 100% negotiated rate for general and specialised wards - subject to pre-authorisation. Services in Hospital Service providers paid up to 200% of CBT* in a general ward unless a more specialised ward is medically indicated. Choice Freedom of choice for Essential Plus; only Life Healthcare and Netcare hospital groups for Essential Network (20% co-payment applies for utilisation of non-DSP hospitals for non-emergencies). Childbirth Confinements General ward. Co-payments No scheme imposed co-payments on surgery or procedures. 20% co-payment applies for utilisation of non-DSP hospitals for non-emergencies. Infertility Treatment PMB only. Radiology and Pathology Unlimited Radiology (including MRI and CT scans) and Pathology - in hospital. Emergency Evacuation Unlimited emergency evacuation - Netcare 911. Additional Chronic Conditions Only Depression. As a minimum requirement, all CAMAF members have, included in their benefits, all PMBs as well as other benefits - see below: PMBs Prescribed Minimum Benefits (PMB) as set down in the Medical Schemes Act, 1998. Medical schemes have to cover the costs related to the diagnosis, treatment and care of: • Any emergency condition. • A limited set of 271 medical conditions, as defined in the Diagnosis and Treatment Pairs (DTP*). • 27 chronic conditions, defined in the Chronic Disease List (CDL). DTP *DTP - the protocols for the treatment and care of PMB conditions should be based on healthcare that has proven to work best, taking affordability into consideration. The minimum standard is the practice and protocol applied in the public sector; however, schemes have the option of providing more extensive care. Such costs may not be paid from a member's savings benefit. Cost saving measures can be used by way of utilising DSPs, Reference pricing and formularies and "evidence based" treatment protocols. *CBT (CAMAF Base tariff) - the maximum tariff paid to providers of health care services. For full details consult the Rules Schedule 1. 2024 ESSENTIAL PLUS & ESSENTIAL NETWORK BACK TO CONTENTS PAGE