Swazimed offers five benefit options and each individual should choose an option according to his/her health care needs. For all the options benefits are paid at 100% of scale of benefits with adequate annual limits.
Note: Swazisave members can claim a 20% saving balance only if the member has 12 months membership from the beginning of the year. Swazimed will only pay this if the member has a tax directive issued by the tax authorities. If the members on the savings option leaves the fund the balance of the savings will remain with the fund and the member may claim the 20% yearly. The current year balance will be paid only if the member leaves by the end of December.
High Benefit Plan offers optional savings to cater for all charges above the SPL and also used for other costs above consultation and medicine limits. All these costs must be within the member’s savings.
Members are not restricted on their optional savings but encouraged to save from E300 for high benefit and from E100 for all other options, plus any amount in the denominations of E100 on monthly basis.
What is managed care and why is it needed?
Managed care aims to reduce the risk posed by disease or injury.
It is a holistic approach to promote health, prevent disease and treat existing disease approximately and cost-effectively, within a given budget.
What is pre-authorisation?
- For non emergency procedures including pregnancy, you need to apply for Pre-Authorization 48 hours before you are admitted to hospital or before you make out-patient visit to hospital. You also obtain pre-authorization before you have a CT scan, MRI scan or Radio-isotope study.
- Pre-authorisation is the PRIOR approval of any planned admission to a hospital or before you make out-patient visit to a hospital and also includes any associated treatment or procedures (including dental procedures) performed during hospitalisation. This enables Swazimed to ensure that you do not go to hospital for treatment that could have been done less cost-effectively and with the same efficiency in an alternative setting (like doctor’s rooms) or stay longer than clinically indicated. That way your medical scheme can ensure better control over future premium increases.
- If you are unsure if pre-authorisation is required, it is recommended that you contact the Authorisation Centre on the contact number listed below.
- The Submitted Hospital Bill must match what was pre-authorised.
What happens in the event of an emergency?
In the event of an emergency treatment/admission to hospital over a weekend, public holiday or at night you MUST contact the Authorisation Centre on the first working date after the incident. If you are still in hospital on the first working day after your admission to the hospital, your hospital will contact the Authorisation Centre on your behalf.
The telephone numbers for pre-authorisation are 800 4001/+268 2404 3718 / 24058400
- Fax number +268 2404 1484
- E-mail request to firstname.lastname@example.org
Who may request pre-authorisation (PAR)?
- Treating Doctor
- Member/Beneficiary/Family Member Intermediary
No/Low Claim Bonus
Members on High, Standard and Medium option from January to December will be allowed to write a letter to claim 30% incentive bonus for the previous year before the end of March in the following year. To qualify for the bonus members should have cleared all contribution arrears by March of the following year. Payment will be between June and October
What information do you need to apply for PAR?
- Your Swazimed membership number
- Date of admission and the proposed date for the operation (this is particularly important as we do not routinely authorise days prior to planned surgery – any such days will have to be applied for and motivated);
Name of the doctor and his/her telephone and practice number, if available;
Name of the hospital with their telephone and practice numbers, if available:
- In the event of a CT scan, MRI Scan, Radio Isotope study etc, the name of the radiology practice is also required;
Ask your doctor for a full description of:
The reason for admission to hospital or reason for scan;
The associated medical diagnosis; and
The planned procedures as well as the tariff codes that the doctor intends to use.