Benefits Guide - 2018 - Sizwe

1 Benefits Guide - 2018pg 2 Sizwe History A Brief history of Sizwe Medical Fund and Sechaba Medical SolutionsIn the late 1960s, Black (African) doctors in the Rand, which consisted of Johannesburg, Pretoria, the Eastrand, and Vereeniging, formed themselves into The S. A. Medical Discussion Group (SAMDG) which discussed matters of interest to Black doctors and their patients. The South African Medical Association was only open to white membership SAMDG met once a month on a Sunday afternoon. Meetings were hosted by members at their homes. Spouses attended meetings and held their own meeting whilst members discussed the business of the day. Meetings ended with a social. The executive of the SAMDG was appointed by region to facilitate executive meetings, in 1976, the executive was from the Eastrand, it was chaired by Dr. Mzamane of Katlegong. It was in 1976 that Dr. Mokgesi who had a practice in Sebokeng, met a white colleague, Dr.

2 Loots at a clinical meeting at the Joburg Gen. Dr. Loots suggested that it would be a good thing to register a medical aid scheme for blacks and a private hospital for blacks, he would introduce the matter to some government officials who would make the registering 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 S African society took up leadership of the group, he led the selling of the idea to black doctors to take up shares, negotiated with white business to support the initiative, and served as chairman of the group. At this time, Dr. Motlana also led various committees of the STRUGGLE which took a great deal of his time and resulted in him spending many months under 1978 The Kwacha Group was registered with 38 shareholders.

3 Dr. Loots was the only white shareholder. He also served on the board of directors. Sizwe Medical Fund was registered, the 38 shareholders raised R3 000 000 as security to meet claims. Lesedi Clinic was to open its doors soon after Sizwe started. (Kwacha meaning Day Break in Chewa was chosen as an appropriate name for the new company). Kwacha was later changed to Sechaba Group Holdings (Pty)LtdSizwe Medical Fund - Benefits Guide 2018pg 3 Sizwe History2018 OfferingsHospital CareGomomo CarePrimary CareAffordable CareFull Benefit CareSizwe History A Brief history of Sizwe Medical Fund and Sechaba Medical SolutionsThe motivation for forming the Kwacha Group To provide medical aid cover for blacks; To enable black specialists to open private practice, black specialists of the day could only work as GPs with specialist qualifications, as specialist fees were only affordable to medical aid members.

4 Black specialists who worked in public hospitals were not recognised, they were humiliated as they could not give orders to white juniors and to white nurses of all ranks! Many black specialists elected to go into exile and practice in the USA and in Canada. To give black private patients and their doctors access to Xray, other investigations and expensive medications which were out of reach for virtually all who had no medical aid cover. To lead the black population in matters of 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 Bonitas for black civil servents, Sanitas for Indians, and Prosano for coloured civil servents. All these schemes were to be administered by Medscheme this is certainly the reason for Bonitas being the second largest open scheme in first members of Sizwe were drawn from the Barlow Rand Group, from Iscor, from PUTCO and from the steel companies and coal mining companies in Witbank and Middleburg as well as motor industry workers from Port Elizabeth and Uitenhage.

5 The initiative by our founding fathers has survived to this day!!Dr Tlakulapg 4 2018 Healthcare OfferingsHOSPITAL CAREPRIMARY CAREGOMOMO CAREThe Hospital Care Option offers peace of mind knowing that in the event of hospitalisation, extensive cover is available at any private hospital. In addition, the Hospital Care Option provides cover for 27 Chronic Disease List (CDL) Care Option offers good value for money with unlimited hospitalisation at any private hospital. This traditional option has generous day-to-day benefitswhich cover acute medicines GPs,specialists, radiology, pathology and more to meet the needs of any is our entry-level option. Gomomo Care Option provides excellent value for money. GPs, specialists and acute medicines are accessible through a selected network provider Dentistry, radiology and pathology are also available from a network provider. No overall limit for hospitalisation at any private hospital.

6 Covers the 27 Chronic Disease List (CDL) conditions. 2018 HEALTHCARE pg 4 2018 Healthcare Offerings - Subject to CMS approvalSizwe Medical Fund - Benefits Guide 2018pg 5 Sizwe History2018 OfferingsHospital CareGomomo CarePrimary CareAffordable CareFull Benefit Care2018 OfferingsFULL BENEFIT CAREOur Full Benefit Care Option offers comprehensive cover and generous Benefits to cover families and individuals who need access to unlimited hospitalisation at any private hospital. This option also offers additional chronic conditions, specialised dentistry, GPs, specialists, acute medication, preventative care Benefits and more rich Benefits . This is the only option which offers Top-up cover when in hospital up to 200% of the Sizwe CAREOur Affordable Care Option offers generous comprehensive cover with unlimited hospitalisation in any private hospital.

7 It also covers additional chronic conditions with specialised dentistry and preventative Benefits . This option is suitable for young and healthy Medical Fund - Benefits Guide 2018 pg5pg 8 Hospital CareHOSPITAL CAREO ffers peace of mind knowing that in the event of hospitalisation, extensive cover is available at any private Medical Fund - Benefits Guide 2018pg 9 Sizwe History2018 OfferingsHospital CareGomomo CarePrimary CareAffordable CareFull Benefit CareIN-HOSPITAL Benefits (All hospital admissions must be authorised. A co-payment of R1 500 will be applied if pre-authorisation was not obtained)AUXILIARY SERVICESG eneral100% Sizwe rateDietician, 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.

8 Day to day: RiskOVERALL 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) - 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: 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 familyOverall limits (Annual)PrincipalMSARisk benefit per familyAdult MSAC hildMSAIN-HOSPITAL Benefits (All hospital admissions must be authorised.)

9 A co-payment of R1 500 will be applied if pre-authorisation was not obtained)Overall annual limitUnlimitedProvider NetworkAnyBENEFITSTop-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. 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 - call 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 benefitSurgeryManaged Care protocols applyGENERAL 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.

10 PMBs subject to pre-authorisation, preferred providers and treatment protocols)HIV/AIDS(Members are encouraged to register with the HIV/AIDS Programme. This benefit includes relevant consultations, counselling, medication and the cost of blood tests for monitoring purposes)Reimbursement rate100% Sizwe rateBenefitNo limits but subject to treatment protocols and PMB s at a DSBH ospital CarePREVENTATIVE CAREWELLNESS SCREENING CONSULTATIONSR eimbursement rate100% Sizwe rateBenefitSubject to a family limit of R2 030 for flu vaccine and pneumococcal vaccine. Mammograms: once in a 2 year cycle for females over 40 years Papsmear: once in a 2 year cycle for females over 21 years Prostate-Spe-cific Antigen (PSA): once per year for males over 40 yearsBLOOD SUGAR, CHOLESTEROL, BLOOD PRESSURE, BMI AND HIVR eimbursement rate100% Sizwe rateBenefitR310 FEMALE CONTRACEPTIVESR eimbursement rateNo BenefitIN-HOSPITAL Benefits (All hospital admissions must be authorised.