Primary Care - 2018 - Sizwe

1 Primary care - 2018pg 2 In 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.

3 Mzamane of Katlehong in the Eastrand appointed its executive was in 1976 that Dr. 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.

4 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. 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 In 1978, the Kwacha Group (Kwacha meaning Day Break in Chewa - a Malawian language) was registered with 38 shareholders.

5 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. 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.

6 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. 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 Primary CAREP rimary care Option offers good value for money with unlimited hospitalisation at a private hospital.

7 This traditional option has generous day-to-day benefits which cover acute medicines GPs, specialists, radiology, pathology and more to meet the needs of any 4 2018 Healthcare Offerings - Subject to CMS approvalpg 12 OUT OF HOSPITAL BENEFITSO ption StructureMajor Medical; Day to day: RiskOVERALL DAY-TO-DAY LIMITB enefitsM: R5 680M+1: R8 410M+2: R9 840M+3: R11 250M+4: R12 680M+5: R14 100M+6+: R15 520 GENERAL PRACTITIONERSR eimbursement rate100% Sizwe rateVisitsM: 4 M+1: 9 M+2: 12 M+3: 14 M+4: 15 M+5: 16 M+6+:17 SPECIALISTS (EXCLUDING PSYCHIATRISTS)Reimbursement rate100% Sizwe rateVisitsAll visits subject to refer-ral from a GP M: 2M+1: 6M+2: 7M+3: 8M+4: 9M+5: 10M+6+.

8 11 ACUTE MEDICINES AND PHARMACY ADVISED THERAPY (PAT) - FALLS WITHIN DAY - TO - DAY BENEFIT WITH THE FOLLOWING SUB-LIMITSR eimbursement rate100% Sizwe rateBenefitsM: R1 770 M+1: R3 190 M+2: R3 550 M+3: R4 030 M+4: R4 140 M+5: R4 370 M+6+:R4 730 CHRONIC CONDITIONS Reimbursement rate100% Sizwe rateBenefitsSubject to PMB chronic conditions, pre-authoris-tion, registration on the chronic disease man-agement programme, formulary and clinical protocolsRADIOLOGY AND RADIOGRAPHYR eimbursement rate100% Sizwe rateBenefitsSubject to managed care protocolsSpecialisedReimburse-ment rate100% Sizwe rateSubject to pre-authorisa-tion and managed care protocolsBenefitsR18 680 per family for in and out of hospitalPHYSIOTHERAPYR eimbursement rate100% Sizwe rate subject to day-to-day benefitsPATHOLOGYR eimbursement rate100% Sizwe rateBenefitsSubject to managed care protocolMENTAL HEALTH(Limited to Psychiatrists.)

9 Clinical and Counselling Psycholo-gists excludes services covered under Auxillary Benefits)Reimbursement rate100% Sizwe rateBenefitsR5 180 per familyOUT OF HOSPITAL BENEFITSDENTISTRY(Subject to Dental Management Programme - accessed through DENIS - 0860 109 556)Conservative DentistryReimbursement rate100% Sizwe rateLimit per beneficiary2 general check-ups a year per beneficiary once in six months. Motivation may be re-quested for extensive re-storative treatment plans (fillings) Root canal treatmentSubject to managed care protocolsPlastic dentures1 set of plastic dentures, full or partial (an upper and a lower) per benefi-ciary in a 4-year periodSPECIALISED DENTISTRY(Subject to pre-authorisation and Dental Management Programme)Benefits100% Sizwe rateCrowns and BridgesNo BenefitOrthodontics (Braces)

10 No BenefitImplantsNo BenefitPartial Metal Frame DenturesNo BenefitSurgeryManaged care protocols applyOPTICAL BENEFITS ACCESSED THROUGH (PPN)Reimbursement rate100% Sizwe rateBenefitsNo limitCycle2 yearsLimit Limit per beneficiaryFramesR320 Single focus lensesR175 per lensBi-focal lensesR380 per lensMulti-focal lensesR380 per lensContact lensesR1 200 AUXILIARY SERVICES (Speech Therapists, Podiatrists, Occupational Therapists, Social Workers, Dieticians, Audiologists, Chiropractors, Homeopathy, Clinical Technologist, Biokineticist and Registered Counsellors)Reimbursement rate100% Sizwe rateBenefitsRisk benefitAnnual limit per familyM.