Possible out-of-pocket expenses for out-of-hospital endoscopy and cataract procedures
The Scheme implemented a rule in 2017 requesting members undergoing an endoscopic procedure (gastroscopy or colonoscopy) or a cataract procedure, to consider having the procedure done in a day clinic or, where appropriate, in the doctor's rooms to prevent a co-payment.
If you are admitted to hospital for these procedures (emergencies excluded), a co-payment of R3 350 for endoscopies and R1 000 for cataract procedures applies to members on the Standard and
Managed Care Plans. Ask your GP, at the time of referral, whether the specialist operates from a day clinic. For more information and a list of day clinics near you, please call us on 0860 222 633 and refer to the November 2016 MediBrief article.
What will be funded by the Scheme for these out of hospital procedures?
Once you obtain authorisation for your endoscopic or cataract procedure, the Scheme will confirm funding according to your plan benefits and the Scheme Reimbursement Rate. The actual procedure, the day clinic contracted rates as well as the consumables used during the procedure will be funded by the
Scheme. Your doctor might prescribe medication for you to take home, post procedure and upon discharge. These medications are referred to as To-Take-Home or To-Take-Out (TTO) medication. Please take note that you will have to pay for the medication from your day-to-day benefits or from your pocket should the facility not have a pharmacy available.