Standard Care Plan: Out of Hospital sublimits explained
Why do we have sublimits for Out of Hospital benefits on the Standard Care Plan and how do they work?
For 2019 your overall Out of Hospital Family Limit is R5 070 per adult and R2 530 per child. If you and one other adult are the only two beneficiaries on the Scheme, your Family Limit will be R10 140. If you are two adults plus one child, it will be R12 670. For more adult or child beneficiaries you would just add the relevant amounts accordingly. This Overall Out of Hospital Limit provides cover for non-PMB day-to-day conditions and has two sublimits, which are also family limits and add up in the same way as the Overall Out of Hospital Limit.
The 2019 Sublimit 1 is R3 275 per adult and R685 per child and is for alternative and allied healthcare services, which include for example audiology, chiropractic services, dietetics, homeopathy, occupational therapy, physiotherapy, psychology, speech therapy and other services. The 2019 Sublimit 2 is R4 760 per adult and R2 380 per child and covers GP and specialist consultations, procedures and treatments in rooms, as well as acute medication and injection material, and Pharmacist Advised Therapy.
These two sublimits do not add up to the overall limit. However, they are both still subject to available funds in the overall limit. This might, at first glance, look confusing or like a shortcoming, but it has advantages. Firstly, it acts as a security net. It allows you to use, for example, all of your family Sublimit 1 on physiotherapy for one family member if needed, but still leaves the family with some benefits for acute medicine and GP or specialist consultations. The amount left over in Sublimit 2 will now be the difference between overall Family Limit and Sublimit 1. In this case, assuming there are two adults on the Scheme, the overall Family Limit will be R10 140 and the total physiotherapy claims paid by the Scheme will be R6 550 (R3 275 + R3 275) leaving a difference of R3 590 for consultations. Secondly, it gives you the flexibility of funding the treatment you need the most in the current year. You might require more alternative or allied healthcare services this year, but next year you might need more GP and specialist consultations. If these were not two different sublimits, you would only have a fixed limit per year for each group of services, as a consequence, you would probably have access to fewer benefits where you need them most.