Hospital Care - 2018 - Sizwe

1 Hospital care - 2018pg 2 Sizwe HistoryIn the late 1960s, black (African) doctors in the Rand, which consisted of Johannesburg, Pretoria, the Eastrand and Vereeniging formed themselves into The South African Medical Discussion Group (SAMDG). The group discussed matters of interest in respect of black doctors and their patients, as the South African Medical Association (SAMA) was only open to white membership specialists could only work as General Practitioners (GPs) with specialist qualifications, as specialist fees were only affordable to medical aid members.

2 Black specialists who worked in public hospitals were not recognised, but were humiliated as they could not give orders to white juniors and white nurses of all ranks. Many black specialists elected to go into exile and practice in the United States of America (USA) and in SAMDG met once a month on a Sunday afternoon, hosted by members at their homes. Spouses attended meetings and held their own meeting while members discussed the business of the day. In 1976, the SAMDG which was chaired by Dr. Mzamane of Katlehong in the Eastrand appointed its executive was in 1976 that Dr.

3 Mokgesi who had a practice in Sebokeng, met a white colleague, Dr. Loots at a clinical meeting at the Johannesburg General Hospital . He suggested that it would be good to register a medical aid scheme and a private Hospital for blacks. He introduced the matter to some government officials who would make registration of a black company in the urban areas possible, as this was not permissible matter of a medical aid scheme and a private Hospital for blacks was discussed by the SAMDG and accepted. Dr. Motlana, who was very influential in black circles and highly respected by business leaders and politicians of all sectors of South African society, assumed leadership of the group.

4 In serving as the chairman of the group, he sold the idea to black doctors to take up shares and negotiated with white business to support the initiative. A Brief history of Sizwe Medical Fund and Sechaba Medical Solutionspg 3 Sizwe HistoryIn 1978, the Kwacha Group (Kwacha meaning Day Break in Chewa - a Malawian language) was registered with 38 shareholders. Dr. Loots was the only white shareholder and also served on the board of directors. Sizwe Medical Fund was registered after shareholders had raised R3 million as security to meet medical claims.

5 Lesedi Clinic opened its doors soon after Sizwe Medical Fund started operating. The Kwacha Group was later changed to Sechaba Group Holdings (Pty) motivation for forming the Kwacha Group To provide medical aid cover for Blacks To lead the black population in matters of healthcare To enable black specialists to open private practice To give black private patients and their doctors access to X-rays, other investigations and expensive medications which were out of reach for virtually all who had no medical aid coverAlthough Dr. Motlana tried to persuade the powers that be to allow black civil servants of the day to join Sizwe , the government refused and instead registered other medical schemes to cater for various civil servants races.

6 The first members of Sizwe Medical Fund were drawn from the Barlow Rand Group, Iscor, PUTCO, steel companies and coal mining companies in Witbank and Middleburg as well as motor industry workers from Port Elizabeth and Uitenhage. Forty years later, the initiative by our founding fathers continues to Tlakulapg 4 2018 Healthcare OfferingsHOSPITAL CAREThe Hospital care Option offers peace of mind knowing that in the event of hospitalisation, extensive cover is available at a private Hospital . In addition, the Hospital care Option provides cover for 27 Chronic Disease List (CDL) 4 2018 Healthcare Offerings - Subject to CMS approvalpg 5 2018 Healthcare OfferingsIN- Hospital BENEFITS(All Hospital admissions must be authorised.)

7 A co-payment of R1 500 will be applied if pre-authorisation was not obtained)AUXILIARY SERVICESG eneral100% Sizwe rateAuxillary Services: Dietician, speech therapy, occupational therapySubject to PMB, clinical protocols and pre-authorisationPHYSIOTHERAPYR eimbursement ratePre-authorisation and managed care protocols apply100% Sizwe rateOUT OF Hospital BENEFITSO ption StructureMajor Medical; Day to day: PMBOVERALL DAY-TO-DAY LIMITB enefitNo benefitGENERAL PRACTITIONERSR eimbursement rateNo benefitSPECIALISTS (excluding psychiatrists), Acute Medicine, Pathologists,Radiologists And PhysiotherapistsReimbursement rateNo benefitBenefitsOnly PMBsACUTE MEDICINES AND PHARMACY ADVISED THERAPY (PAT)

8 - FALLS WITHIN DAY-TO-DAY BENEFIT WITH THE FOLLOWING SUB-LIMITSR eimbursement rateNo benefitRADIOLOGY AND RADIOGRAPHYG eneralReimburse-ment rateNo benefitSpecialistReimburse-ment rateNo benefitPHYSIOTHERAPYR eimbursement rateNo benefitPATHOLOGYR eimbursement rateNo benefitBASIC DENTISTRYR eimbursement rateNo benefitSPECIALISED DENTISTRYR eimbursement rateNo benefitOPTICAL BENEFITS ACCESSED THROUGH PPNR eimbursement rateNo benefitMENTAL HEALTHR eimbursement rateNo benefitAUXILIARY SERVICES(Chiropractic Treatment, Homeopathy)Reimbursement rateNo benefitMATERNITYS ubject to registration on the Sizwe Baby Programme within 24 weeks of falling pregnantReimbursement rate100% Sizwe rateAnte-natal consultationsAnte-natal consultation: 9 GP, Midwife Visits2 Obstetrician visitsPregnancy scans and blood tests2 x 2D scansBlood tests.

9 Two (2) Haemoglobin Measurement tests, One (1) Blood Grouping test, One (1) VDRL test for Syphilis and One (1) HIV blood testFertilityNo benefitsPSYCHOLOGICAL AND PSYCHIATRIC TREATMENTR eimbursement rateNo benefitMEDICATIONA cuteReimburse-ment rateNo benefitsOTCR eimburse-ment rateNo benefitsCHRONIC CONDITIONSPMB100% negotiated tariff at Preferred Provider NetworkNon-PMBNo benefitLimitsFormulary, limit per familyIN- Hospital BENEFITS(All Hospital admissions must be authorised. A co-payment of R1 500 will be applied if pre-authorisation was not obtained)Overall annual limitUnlimitedProvider NetworkContractedBENEFITSTop-up coverNo benefitCo-PaymentsGeneral scopes R1 300 Endoscopic (Laparoscopic surgery) investigationsR3 000 AMBULANCE SERVICESC ontracted EUROP ASSISTSA (Telephone number:0860 11 77 99100% Sizwe ratePRIVATE HOSPITALS AND NURSING HOMES(Subject to treatment and case management protocols and PMBs.))

10 Pre-authorisation required unless it is a medical emergency)AccommodationUnlimited at any private hospitalReimbursement rate100% Sizwe rateClinical limitations and exclusionsNoneDENTISTRY(Subject to Dental Management Programme - accessed through DENIS - 0860 109 556)Conservative DentistryReimbursement rate100% Sizwe rateSubject to pre-autho-rised and managed care protocolsSpecialised Dentistry(Subject to pre-authorisation and Dental Management Programme)Reimbursement rate100% Sizwe rateCrowns and BridgesNo benefitOrthodontics (Braces)No benefitImplantsNo benefitPartial Metal Frame DenturesNo benefitGENERAL PRACTITIONER AND MEDICAL SPECIALISTR eimbursement rate100% Sizwe rate for consultations and visits in-hospitalCHRONIC BENEFITSS ubject to :subject to registration on the Chronic Medicine Programme.