Bestmed Beat 1 Option

Contributions
Non-Network/Network Principal Member Adult Dependant Child Dependant*
Risk Amount NN R1 363 R1 058 R573
N R1 226 R953 R516
Savings Amount NN – – –
N – – –
Total Monthly Contribution NN R1 363 R1 058 R573
N R1 226 R953 R516

* You only pay for a maximum of 4 children. All other children can join as beneficiaries of the Scheme free of charge.

Summary:

  • No savings option is available
  • Scheme rate is 100%
  • Most day-to-day expenses are paid from out of pocket, unless PMBs
  • You must use a network hospital
  • Treatment and medicine for 27 chronic conditions covered by scheme
  • Cancer (PMB only) is treated in state hospitals, but you can upgrade to higher plan on cancer diagnosis to receive private hospital treatment
  • There are co-payments for in-hospital MRIs and CT Scans (gap cover pays this co-payment)
  • There is a benefit for out-of-hospital specialised radiology (paid in full with gap cover)
  • Diagnosis and treatment of the 270 PMBs is always paid by scheme, in and out of hospital, according to protocols.
In-Hospital Benefits
Specialists:
  • Up to 100% scheme rate
Hospital Choice:
  • Network hospitals, or up to R10 000 co-payment for non-network hospitals
Specialised Radiology:
  • R3 200 co-payment for private hospitals
Supplementary Services: (Physio, etc)
  • 100% of scheme rate
Transplants:
  • Bestmed pays for treatment of PMBs only
Co-payments:
  • Scopes: R3 200 co-payment for private hospitals
  • Specialised radiology: R3 200 co-payment for private hospitals
Alternatives to hospitals:
  • 100% of scheme rate
Casualty:
  • Only PMBs
Other:
  • none
Out-of-Hospital Benefits
Savings available:
  • No savings available
General info:
  • This plan has no savings fund, so most out-of-hospital costs are paid by you
  • Out-of-hospital costs authorised as part of PMB treatment (eg. cancer, asthma or stroke) are paid by Bestmed
GP consultations:
  • Out of your own pocket
Childcare:
  • No extra benefits
Specialists consultations:
  • Out of your own pocket
Pathology:
  • Out of your own pocket
General radiology:
  • Out of your own pocket
Specialised radiology:
  • R4 500 per family
Supplementary Services: (Physio, etc)
  • Out of your own pocket
Maternity Benefits
Hospital stay:
  • Up to scheme rate, includiing for births with midwife
Consultations:
  • Out of your own pocket
Scans:
  • Out of your own pocket
Oncology (Cancer) Benefits
Overall coverage (in and out of hospital):
  • Bestmed will pay for cancer treatment in a state hospital only, and only for PMBs.
  • If you are diagnosed with cancer while on this plan, you can upgrade your plan immediately to receive cover at private hospital
Dentistry Benefits
Dentistry:
  • Out of your own pocket
  • PMB conditions (eg. fracture of face bones, orbit or/and jaw) are always paid by schemes.
Orthodontics:
  • Out of your own pocket
Maxillo Facial Surgery:
  • Out of your own pocket, unless it’s to treat a PMB.
  • PMB conditions (eg. fracture of face bones, orbit or/and jaw) are always paid by schemes.
Medication Benefits
Chronic:
  • All medical aid plans pay for treatment of the 27 CDL conditions as required by law. This includes medicine as well as GP or specialist consults, tests etc.
  • 40% co-payment if not on Bestmed’s formulary list
Acute (presrcibed) medication:
  • Out of your own pocket
Over-the-counter:
  • Paid from day-to-day benefit
Birth Control:
  • R1 950 per family per year, paid by Bestmed
On Discharge:
  • 7 days
Biological:
  • Out of your own pocket
Optometry Benefits
Optometry:
  • Out of your own pocket, unless for an approved in-hospital or day clinic procedure
  • PMB conditions are always paid by schemes
  • Refractive surgery: No benefit
Mental Health Benefits
In-hospital:
  • Bestmed will pay for up to 21 days per person at 100% scheme rate, and may require use of specific providers
  • Cover for PMB mental conditions is always paid for by scheme, in and out of hospital
Out-of-hospital:
  • Cover for PMB mental conditions is always paid for by scheme, in and out of hospital
  • For non-PMB conditions, you pay this out of pocket
Trauma:
  • PMB conditions are covered for in and out of hospital treatment
  • Example of PMB condition: Acute stress disorder accompanied by recent significant trauma>, including physical or sexual abuse. Treatment includes hospital admission for psychotherapy / counselling up to 3 days, or up to 12 outpatient psychotherapy / counselling contacts
Other Benefits
General Appliances:
  • Out of your own pocket
1.1. Hearing Aids:
  • Out of your own pocket
1.2. Wheelchairs:
  • Out of your own pocket
Dialysis:
  • Bestmed only pays for PMB cases, with a designated network provider
HIV:
  • Managed care programme
Emergency Transport:
  • ER24
International Insurance:
  • TBC
Other:
  • Wound care: R2 970 per family, paid by scheme
Preventative Benefits
Flu vaccination:
  • Covered
Pneumonia vaccines:
  • Covered
Back Rehabilitation Programme:
  • Covered
Biometric Screening:
  • Covered
Child Immunisation:
  • Covered
Pap Smear:
  • Covered: 18yrs+ every 2 years
Mammogram:
  • No benefit
PAS Test:
  • No benefit
HIV Test:
  • TBC
Other:
  • No benefit
Prosthetic Benefits
Overal Limit:
  • Internal: R66 400 per family
  • External: no benefit
Sub-limits:
  • Functional (treating or supporting a bodily function): R11 880
  • Vascular: R26 500
  • Pacemaker, dual chamber: R36 200
  • Spinal: R26 500
  • Mesh: R9 300
  • Gynaecology/Urology: R7 600
  • Lens implants: R5 800 per lens

Exclusions:

  • Endovascular and catheter-based procedures
  • Artificial disk
  • Drug eluting stents
  • Joint replacements, unless PMBs

PMB joint replacements:

  • Hip replacement and other major joints: R27 900
  • Knee replacement: R34 400
  • Minor Joints: R10 700