CompCare Medical Scheme

CompCare positions this at people under 30 starting their first job, and the family rate table pointedly says families should look at options with child benefits instead. There is a child rate of R986 and no published age restriction, so the positioning is advice rather than a rule.

• The GP benefit is the reason to buy it. Unlimited virtual consultations at 100% of the CompCare rate, including acute medicine to R470 per event at a designated provider. Unlimited face-to-face consultations with a R110 co-payment each, which you may pay out of your savings account. Pre-authorisation is required from the seventh visit per beneficiary.
• Savings account of R3 372 for a member or adult and R1 164 for a child, which is 10% of the contribution. It is advanced in full in January, unused money rolls over, and it pays for medicine, dentistry, optometry, appliances and co-payments.
• One conservative dental consultation per beneficiary and one eye test every 12 months are paid from risk rather than from savings.
• Specialists are the weak point. Two consultations per family per year, capped at R2 350 in total, with a R130 co-payment each, and only on GP referral. After that you pay.
• Hospitalisation is unlimited at 100% of the CompCare rate in Netcare or Mediclinic hospitals only.
• Chronic cover is the 27 Chronic Disease List conditions plus a R170 a month depression medicine benefit. Nothing else.
• MRI and CT are limited to R23 920 a family in and out of hospital combined, with a R3 950 co-payment for each scan.
• Cancer is Prescribed Minimum Benefits only, unlimited at the oncology designated service provider. A non-designated provider is paid at 100% of the CompCare rate.
• Specialised medication is PMB only.
• The exclusion list is where this option stops being cheap. Joint replacement, laminectomy and spinal fusion, Nissen fundoplication, hysterectomy other than for cancer, major laparoscopic surgery including hernia repair, and conservative back and neck treatment are all excluded unless they qualify as PMBs. Diagnostic scopes, functional nasal surgery, arthroscopy and in-hospital dental surgery are PMB only. Internal nerve stimulators, cochlear implants, insulin pumps and CPAP machines are excluded outright.

A savings account with an insured benefit stacked behind it, and the cheapest option in the range that lets you use any private hospital. A family of four is R10 696.

• Savings account of R7 896 for a member, R6 588 an adult and R2 352 a child, at 15% of the contribution. Claims come out of savings first, except PMBs.
• Once the savings are empty, the Annual Flexi Benefit of R5 272, R4 404 and R1 579 takes over. It is the Scheme's money, not yours.
• Read the Flexi Benefit sub-limits before you rely on it. Within that benefit, radiology, pathology, conservative dentistry, specialised dentistry and surgical and medical appliances are each limited to R2 080 per family. Optometry and over-the-counter medicine get no Flexi Benefit at all. In practice the Flexi Benefit funds GP visits, specialists and acute medicine, and very little else.
• Any private hospital, unlimited, at 100% of the CompCare rate.
• Specialists are unlimited from the day-to-day pool on GP referral, which is a large step up from SelfCare Plus.
• 12 antenatal visits through the Care Maximiser, against 8 on SelfCare Plus.
• 27 Chronic Disease List conditions plus the R170 depression medicine benefit.
• MRI and CT to R31 200 a family, R3 950 co-payment a scan. Cancer is PMB only, unlimited at the oncology designated provider.
• The elective surgery co-payments are the highest in the range that still allow the procedure: R30 000 for a joint replacement, R30 000 for laminectomy and spinal fusion, R26 520 for reflux surgery, R19 550 for a hysterectomy, R12 480 for functional nasal surgery, R10 400 for an arthroscopy and R5 820 for a diagnostic scope.
• Psychology for a non-psychiatric admission is capped at R2 280 a family.

A pure hospital plan on the Netcare network. It is the only option in the range with no day-to-day benefit of any kind, and the only one with a flat deductible on elective surgery.

• Unlimited hospitalisation at any Netcare hospital, at 100% of the CompCare rate, with unlimited in-hospital GP and specialist treatment.
• An overall co-payment of R15 600 applies to elective surgery, and if the procedure costs less than R15 600 you are liable for the full cost of it. That is the single most expensive rule anywhere in the CompCare range and it applies to planned surgery generally, not to a defined list.
• Preventative care and wellness of R10 400, the lowest in the range, covering the essential health test, HIV tests, flu, tetanus and pneumococcal vaccines, PSA, colorectal screening, lipogram, Pap smear, mammogram, HPV vaccine, travel vaccines, malaria prophylaxis and childhood immunisations to age 12.
• Unlimited telephonic psychosocial counselling from risk, with up to three face-to-face referral sessions per beneficiary a year.
• Unlimited virtual nurse consultations at a designated provider, paid from risk.
• Chronic cover is the 27 Chronic Disease List conditions, PMB only, at designated provider pharmacies.
• Confinements, both hospital and home births, are unlimited.
• Internal prosthesis limit of R37 540 a family, but all orthopaedic prostheses are excluded: hip, knee, shoulder, elbow, ankle, wrist, finger, spinal instrumentation, spinal cages and internal fixators.
• MRI and CT to R28 600 a family, with no benefit for PET scans and a R3 950 co-payment for each scan.
• Pathology is limited to R31 200 a family for non-PMBs. Auxiliary services such as physiotherapy are limited to R3 540 a family for non-PMBs.
• No savings account, no Flexi Benefit, no Care Maximiser, no GP benefit, no dentistry, no optometry, no acute medicine. Everything outside hospital and the preventative list is yours.
• Arthroscopy, conservative back and neck treatment, back and neck surgery, joint replacement, spinal surgery, reflux surgery and hearing aids are excluded outside PMBs. Cancer is PMB only.

No savings account. Instead a pooled day-to-day benefit, a second pool called the Day-to-Day Extender Benefit for the things that usually drain a savings account, and a separate optometry benefit.

• Day-to-Day Benefit of R6 970 for a member, R4 890 an adult and R2 490 a child. It pays GPs, specialists, chronic and acute medicine, over-the-counter medicine, specialised dentistry, auxiliary services, clinical psychology and psychiatry, home oxygen, appliances and home nursing.
• Day-to-Day Extender Benefit of R6 970 per beneficiary, capped at R10 880 a family, for out-of-hospital radiology, pathology, basic dentistry, physiotherapy and biokinetics. Keeping those five things in a separate pool is the point of the option.
• Optometry benefit of R6 760 a family, which covers one eye test every 24 months, lenses to R1 190 per beneficiary and frames to R680, all within that R6 760.
• Hospitalisation is unlimited at Netcare or Mediclinic hospitals.
• 41 chronic conditions: the 27 on the Chronic Disease List plus 13 more, plus the depression medicine benefit.
• Pathology carries an overall limit of R43 370 a family for in and out of hospital combined.
• Specialised medication for non-PMBs to R192 400 a family, with a 25% co-payment.
• Cancer is unlimited at the oncology designated service provider, at 100% of the CompCare rate, subject to the oncology formulary. This is the cheapest option in the range with cancer cover beyond PMBs.
• Co-payments remain substantial: R26 000 on a joint replacement, R25 000 on laminectomy and spinal fusion, R20 800 on reflux surgery, R10 400 on functional nasal surgery, R7 800 on an arthroscopy, R4 580 on a diagnostic scope and R4 500 on dental work.
• Nothing rolls over. An unused day-to-day benefit is gone on 31 December.
• Spinal instrumentation, spinal cages and spinal implantable devices are PMB only, and CPAP machines, insulin pumps, internal nerve stimulators and cochlear implants are excluded.

Identical benefits. The only difference is the hospital network: UltraCare is Netcare, UltraCare Plus is any private hospital. That freedom costs R1 844 a month for a member, R1 659 for an adult and R646 for a child, which works out at R4 795 a month for a family of four.

• Annual Flexi Benefit of R16 640 for a member, R12 480 an adult and R4 780 a child, to a maximum of three children.
• Self-Payment Gap of R10 608, R7 900 and R2 910. GP and specialist consultations, prescribed acute medicine, radiology and pathology accumulate towards the Annual Threshold of R27 248, R20 380 and R7 690.
• Above Threshold Benefit of R10 050 per beneficiary, capped at R17 890 a family.
• 66 chronic conditions: the 27 on the Chronic Disease List plus 39 more. Designated provider pharmacies apply, with a 25% co-payment for using another pharmacy and 25% for non-formulary medicine.
• MRI, CT and basic radiology are unlimited, with the standard R3 950 co-payment per scan for non-PMBs. Pathology is unlimited.
• Out-of-hospital clinical psychology to R3 220 a family and psychiatry to R13 570 a family, both from the Flexi Benefit, with no Above Threshold cover for either.
• Conservative dentistry to R4 890 per beneficiary and specialised dentistry to R16 020 per beneficiary and R21 630 a family. Neither gets Above Threshold cover.
• Two eye tests a year, lenses to R4 990 and one frame to R2 160 every 12 months. Refractive eye surgery to R8 680 per eye, which has to cover the hospital account too.
• Specialised medication for non-PMBs to R271 440 a family with a 25% co-payment. Internal nerve stimulators to R142 480 and cochlear implants to R250 740, both excluded on the cheaper options.
• Elective surgery co-payments drop sharply here: R4 160 for a joint replacement, spinal fusion or reflux surgery, R3 430 for a hysterectomy or major laparoscopic surgery, R3 410 for a scope, arthroscopy or nasal surgery and R3 280 for dental.
• Specialists are still paid at only 100% of the CompCare rate, in and out of hospital. If your surgeon bills more, that gap is yours.
• Over-the-counter medicine is capped at R1 090 per beneficiary and R1 560 a family, one prescription a day, R250 an event, and gets no Above Threshold cover.

The top of the range. Again the two are identical except for the network: ExecuCare is Netcare, ExecuCare Plus is any private hospital, for R1 453 a month more on a member.

• In-hospital specialists are paid at 150% of the CompCare rate, excluding dental treatment, with GPs at 100%. Out of hospital, specialists are paid at 150% but accumulate towards the Annual Threshold at 100%. No other option in the individual range pays above 100%.
• Annual Flexi Benefit of R22 930, R17 470 and R6 340, with a Self-Payment Gap of only R5 200, R3 120 and R1 040. Annual Threshold of R28 130, R20 590 and R7 380. Above Threshold Benefit of R11 700 per beneficiary to R23 920 a family.
• 75 chronic conditions: the 27 on the Chronic Disease List plus 47 more, with medicine for non-Chronic Disease List conditions unlimited rather than capped.
• No co-payment on any listed elective procedure. Joint replacements, spinal fusion, reflux surgery, hysterectomy, scopes, arthroscopy, nasal surgery, dental, grommets and tonsillectomy all carry no co-payment, and specialised medication carries none either.
• Specialised medication for non-PMBs to R374 400 a family.
• Internal prosthesis limit of R62 400 a family, the highest in the range, with spinal instrumentation at R32 550 for the first level and R60 840 for two or more.
• Out-of-hospital clinical psychology to R6 510 a family and psychiatry to R23 880 a family, roughly double UltraCare.
• Conservative dentistry to R6 970 per beneficiary, specialised dentistry to R18 720 per beneficiary and R24 960 a family. Optometry lenses to R6 140, frames to R3 120, refractive surgery to R9 770 per eye.
• Home nursing to 60 days a family, against 40 on UltraCare.
• The MRI and CT co-payment of R3 950 a scan still applies, and dentistry and optometry still get no Above Threshold cover.
• A family of four is R30 443 on ExecuCare and R34 220 on ExecuCare Plus. At that price the specialist reimbursement rate of 150% is modest by market standards.

CompCare describes this as a premium healthcare solution for employers and their staff. It is not sold to individuals. On several measures it is the strongest option in the range, and on the child rate it is dramatically cheaper than the individual options near it.

• In-hospital specialists are paid at 200% of the CompCare rate, excluding dental specialists, with GPs at 100%. That is the highest reimbursement rate CompCare publishes anywhere.
• Any private hospital, unlimited, with no co-payment on any listed elective procedure. Diagnostic scopes are the exception: R4 470 for a gastroscopy in a day clinic or R5 600 in hospital, R4 300 for a colonoscopy in a day clinic or R6 250 in hospital.
• 25% savings account: R29 100 a year for a member, R27 648 an adult and R5 808 a child. That is the largest savings allocation in the range by a wide margin.
• Self-Payment Gap of R4 545 for a member, R6 136 an adult and R624 a child. Note that the adult gap is larger than the member gap here, which is the reverse of every other CompCare option. Above Threshold Benefit of R36 400 for a member and an adult and R8 840 a child.
• 75 chronic conditions, the 27 on the Chronic Disease List plus 48 more.
• Acute medicine limits scale with family size: R41 760 for a member alone, R48 930 with one dependant, R56 830 with two and R64 790 with three or more.
• Combined conservative and specialised dentistry to R35 880 a family, and a combined optometry benefit of R7 540 per beneficiary covering visits, lenses, frames, intra-ocular lenses and refractive surgery every 12 months.
• MRI and CT unlimited, with the R3 950 per-scan co-payment paid from savings.
• Internal prosthesis limit of R62 400 a family, matching ExecuCare Plus.
• The Annual Threshold amount is not published in the SuperCare Plus summary, only the savings account, the Self-Payment Gap and the Above Threshold Benefit. Ask your employer or the scheme for it in writing.
• Dental co-payments are the one place SuperCare Plus is worse than ExecuCare: R8 580 in hospital or R5 510 in a day clinic, and R3 330 or R1 510 for children under 13.

Every option covers the diagnosis, treatment and care of emergency medical conditions and the 27 Chronic Disease List conditions that the Medical Schemes Act requires. CompCare publishes four steps to getting PMB cover, and skipping any of them is how members end up paying:

1. If you need hospitalisation, make sure your specialist operates in a network hospital, unless it is an emergency.
2. Apply for pre-authorisation of the condition.
3. Familiarise yourself with the authorised medical treatment schedule that CompCare provides.
4. Use the preferred designated service provider pharmacy for chronic medicine, as required by your option.

Above the statutory 27, the options add their own lists. The totals CompCare publishes are 28 on SelfCare Plus and SaverCare Plus, 27 on HospiCare, 41 on ExtraCare, 66 on UltraCare and UltraCare Plus, and 75 on ExecuCare, ExecuCare Plus and SuperCare Plus. The additional conditions include allergic rhinitis, angina, ankylosing spondylitis, anorexia and bulimia nervosa, attention deficit disorder, benign prostatic hyperplasia, deep vein thrombosis, emphysema, generalised anxiety disorder, gastro-oesophageal reflux disease, gout, hormone replacement therapy, migraine, motor neuron disease, obsessive compulsive disorder, osteoarthritis, osteoporosis, panic disorder, paraplegia and quadriplegia, post-traumatic stress syndrome, psoriasis, stroke, unipolar mood disorder and vertigo.

How chronic medicine is paid

• Chronic medicine is paid at 100% of the reference price on every option, subject to formularies, protocols and pre-authorisation.
• On SelfCare Plus it comes from the savings account first. On SaverCare Plus, ExtraCare, UltraCare and ExecuCare it comes from the day-to-day benefit first, and the Scheme picks it up once that benefit is exhausted. On SuperCare Plus it comes from the savings account first.
• Non-formulary medicine carries a 25% co-payment on every option.
• Designated service provider pharmacies apply on ExtraCare, UltraCare, ExecuCare, HospiCare and SuperCare Plus, and using another pharmacy adds a second 25% co-payment.
• Medicine for conditions that are not on the Chronic Disease List is capped at R3 740 a family on UltraCare within the Above Threshold Benefit and is unlimited on ExecuCare. On SelfCare Plus and SaverCare Plus there is no non-Chronic Disease List medicine benefit beyond the R170 a month for depression.
• Your doctor or pharmacist applies for chronic benefits by contacting Universal Care directly. Application forms are no longer used.

A R170 per beneficiary per month depression medicine benefit runs across all eight options that have day-to-day cover, paid from day-to-day benefits first and then from risk.

Four mechanisms, and which ones you have depends entirely on your option.

1. Personal Medical Savings Account. On SelfCare Plus at 10% of contribution, SaverCare Plus at 15% and SuperCare Plus at 25%. It is advanced in full on 1 January, or pro rata if you join later, and unused money carries over for as long as you stay on an option with a savings account. If you leave mid-year having spent more than the pro-rata share, you owe the Scheme the difference. If you leave with a positive balance, it is paid to you or transferred to your new scheme in the fifth month after resignation.
2. Annual Flexi Benefit. An insured amount on SaverCare Plus, UltraCare, UltraCare Plus, ExecuCare and ExecuCare Plus. It is the Scheme's money, with its own sub-limits, and it does not carry over.
3. Self-Payment Gap. On UltraCare, UltraCare Plus, ExecuCare, ExecuCare Plus and SuperCare Plus. You fund this stretch yourself. Only GP and specialist consultations, prescribed acute medicine, radiology and pathology accumulate towards the Annual Threshold on UltraCare and ExecuCare. On SuperCare Plus dentistry and optometry accumulate too.
4. Above Threshold Benefit. Once the threshold is reached, the Scheme pays specified day-to-day expenses again, up to R10 050 a beneficiary on UltraCare, R11 700 on ExecuCare and R36 400 a member on SuperCare Plus.

SelfCare Plus, HospiCare and ExtraCare have no threshold and no Above Threshold Benefit at all. On ExtraCare, when the Day-to-Day Benefit, the Extender and the optometry benefit are used up, the year is over as far as out-of-hospital cover goes.

Maternity cover comes largely through the Care Maximiser rather than through your day-to-day benefits, which means you have to activate the Care Maximiser by having all adult beneficiaries complete the essential health test at a designated provider pharmacy.

• Antenatal visits with a GP, specialist or midwife: 8 on SelfCare Plus, 12 on SaverCare Plus, ExtraCare, UltraCare, UltraCare Plus, ExecuCare, ExecuCare Plus and SuperCare Plus. On the savings options they are paid from the savings account first.
• Two 2D ultrasound scans a pregnancy at 100% of the CompCare rate. 3D scans are paid at the 2D rate.
• 8 to 12 antenatal classes and a lactation consultation with a midwife, worth between R1 560 and R1 870 a pregnancy depending on the option.
• A maternity bag on registration with the maternity programme, a flu vaccine during pregnancy, and one additional nutritional and fitness assessment per pregnancy.
• A breast pump per pregnancy, on options with a savings account, to R3 330.
• Confinements are unlimited at 100% of the CompCare rate on every option, covering natural birth, caesarean section and home delivery, with no overall annual limit. Pre-authorisation is required when you book your bed.
• Seven days of take-home medicine on discharge.
• Register the baby within 30 days of birth for immediate cover.
• Elective caesarean sections for non-medical reasons are excluded on every option.
• Infertility treatment, including artificial insemination, IVF, GIFT, ZIFT and ICSI, is excluded on every option.

Child benefits

CompCare funds a set of child benefits from risk rather than from your day-to-day money: newborn hearing screening and the congenital hypothyroidism test, two baby wellness visits a year for children from four weeks to 18 months at a designated provider, childhood immunisations to the Department of Health schedule up to age 12, three additional paediatric consultations, one additional emergency room visit for children under 6, school readiness assessments including psychometric testing at 14 to 18, preschool eye and hearing screening at 5 to 6 and dental screening at 5 to 7, an initial occupational therapy consultation, kids fitness and nutrition programmes for ages 8 to 15, the SporTeen fitness benefit for 13 to 17, and hearing aids for children under 12 to R6 500 on every option.

Through the Care Maximiser, children under 6 get unlimited GP consultations and unlimited basic dentistry, plus an emergency room visit capped at R1 610 an event unless it is a PMB.

CompCare's oncology cover splits the range cleanly in two, and the split does not follow price.

ExtraCare at R6 968 is therefore the cheapest CompCare option with cancer cover beyond PMBs, and HospiCare at R5 192 is a hospital plan whose cancer cover is PMB only.

Where the money often actually goes on a cancer claim is specialised medication, and that is limited separately: PMB only on SelfCare Plus and SaverCare Plus, R192 400 a family on ExtraCare, R271 440 on UltraCare and UltraCare Plus, and R374 400 on ExecuCare and ExecuCare Plus. A 25% co-payment applies on non-PMB specialised medicine everywhere except ExecuCare and ExecuCare Plus, which have none.

Universal Care handles oncology pre-authorisation and your doctor applies on your behalf. Oncologist consultations do not need a GP referral once you are on an approved oncology management programme. Prophylactic mastectomy and hysterectomy are covered at 100% of the CompCare rate on every option, and the cancer prevention bundle waives the co-payment on an elective hysterectomy where there is a family history across three generations of breast, uterine or ovarian cancer.

Mental health is one of the areas where CompCare's cheaper options are stronger than you would expect, because the counselling benefit is funded from risk on every option including HospiCare.

• Psychosocial counselling: unlimited telephonic counselling sessions through the Universal Wellness Care Centre, paid from risk, on all nine options. Up to three referral sessions per beneficiary a year with a qualified psychologist, social worker or registered counsellor. The line is 0800 390 003, free, 24 hours a day, or send a "Please call me" to *134*952#.
• In-hospital psychiatric treatment: up to 21 days' admission or 15 consultations, on every option, at 100% of the CompCare rate. The 15 consultations come out of your day-to-day benefit first and the Scheme covers them after that. Pre-authorisation and protocols apply.
• Alcoholism, drug dependence and narcotics: unlimited for PMBs on every option, subject to pre-authorisation.
• Out-of-hospital psychology and psychiatry is where the options separate. On SelfCare Plus it comes from the savings account for non-PMBs. On SaverCare Plus it comes from savings. On ExtraCare it comes from the Day-to-Day Benefit. UltraCare and UltraCare Plus give clinical psychology a sub-limit of R3 220 a family and psychiatry R13 570 a family. ExecuCare and ExecuCare Plus give R6 510 and R23 880.
• Psychology for a non-psychiatric admission: from savings on SelfCare Plus, R2 280 a family on SaverCare Plus, R3 260 on ExtraCare, R4 650 on UltraCare and R5 970 on ExecuCare.
• A R170 per beneficiary per month depression medicine benefit runs across the range, paid from day-to-day benefits first and then from risk.
• A GP referral is required for clinical psychology and psychiatry, and the 35% penalty for going without one applies here too.
• Sleep therapy and polysomnograms are excluded on every option, and CPAP machines are excluded on SelfCare Plus, HospiCare and ExtraCare.

Neither is well funded anywhere in the range, and on UltraCare and ExecuCare neither gets any Above Threshold cover, so the Flexi Benefit is the ceiling.

Specialised dentistry needs a quotation approved before treatment starts, and Universal Care runs a pre-authorisation service for it. Orthodontic treatment for anyone over 18 is excluded on every option, along with tooth bleaching, lingual orthodontics, osseo-integrated implants and all implant-related procedures, orthognathic surgery, resin bonding of metal fillings, and conscious sedation or general anaesthetic for dental procedures from age 7 upwards.

Refractive eye surgery is paid from savings on SelfCare Plus and SaverCare Plus, comes out of the R6 760 optometry benefit on ExtraCare, and is limited to R8 680 an eye on UltraCare and R9 770 an eye on ExecuCare. Those limits have to cover the hospital account and all related costs as well.

The overall internal prosthesis limit per family is R33 280 on SelfCare Plus, R37 540 on HospiCare, R38 220 on SaverCare Plus, R43 680 on ExtraCare, R48 880 on UltraCare and UltraCare Plus and R62 400 on ExecuCare, ExecuCare Plus and SuperCare Plus. Coronary artery stents sit inside that limit with a sub-limit of R14 560 a stent on every option.

• Hip, knee and shoulder prostheses: R34 940 on SaverCare Plus, R35 000 on ExtraCare, R42 120 on UltraCare and R43 370 on ExecuCare. On SelfCare Plus they are PMB only and on HospiCare they are excluded.
• Spinal instrumentation: R12 480 a level on SaverCare Plus, PMB only on ExtraCare, R26 210 on UltraCare, and R32 550 for the first level with R60 840 for two or more levels on ExecuCare. Limited to one procedure per beneficiary a year.
• Cochlear implants and bone-anchored hearing aids: R250 740 on UltraCare and ExecuCare, excluded on SelfCare Plus, SaverCare Plus, ExtraCare and HospiCare.
• Internal nerve stimulators: R142 480 on UltraCare and ExecuCare, excluded on the rest.
• Insulin pumps: R29 020 every five years on UltraCare and ExecuCare, from savings on SaverCare Plus, excluded on SelfCare Plus, ExtraCare and HospiCare.
• Hearing aids for adults: R11 340 on ExtraCare, R21 630 on UltraCare and R28 500 on ExecuCare, every three years. Excluded on SelfCare Plus and HospiCare. Hearing aids for children up to 12 are R6 500 on every option except HospiCare.
• CPAP machines: R12 790 on UltraCare and ExecuCare, from savings on SaverCare Plus, excluded elsewhere.
• Wheelchairs: R1 300 on ExtraCare, R5 250 on UltraCare, R5 430 on ExecuCare.

Excluded on every option, subject to PMBs

Bariatric surgery and obesity treatment, breast reduction and gynaecomastia surgery, bunion surgery, elective caesarean sections for non-medical reasons, cosmetic surgery including blepharoplasty and otoplasty, corneal transplants, deep brain implants, gender reassignment surgery and medicines, infertility treatment, investigations and diagnostic work-ups done only in hospital, polysomnograms and CPAP titrations, removal of port-wine stains, scars and tattoos, reversal of vasectomy or tubal ligation, robotic assisted surgery, sleep therapy, keloid treatment other than after burns or for functional impairment, medicine not registered by SAHPRA, clinical trial medicine, anabolic steroids and immunostimulants, vitamins and minerals, ventricular assist devices and artificial hearts, TENS machines, hospital beds, health shoes, incontinence products, mattresses, motorised scooters, shower and bath rails, prescription and non-prescription sunglasses, genetic and metabolic testing, aphrodisiacs, smoking cessation agents, contact lens preparations and cosmetic preparations.

On top of that, SelfCare Plus and HospiCare exclude back and neck surgery, joint replacement surgery, reflux and hiatus hernia repair surgery, functional nasal and sinus surgery, and arthroscopic surgery, and HospiCare also excludes hearing aids entirely. SelfCare Plus additionally excludes in-hospital dental surgery beyond what the savings account pays and treats excimer laser and refractive surgery as a savings claim.

The preventative list is identical across the eight non-HospiCare options and paid from risk, not from your day-to-day money. It covers one essential health test per beneficiary over 18 at a designated provider pharmacy, limited to R300 an event, covering blood pressure, blood sugar, cholesterol, BMI and waist circumference. Then rapid HIV tests as required, malaria prophylaxis, one flu vaccine a year, a tetanus injection when required, one PSA test a year for men over 40, colorectal cancer screening every 24 months for beneficiaries between 45 and 75, one glaucoma test a year, one fasting lipogram every five years for beneficiaries over 20, one Pap smear a year for women over 18, a mammogram every second year for women over 35, one HPV vaccine course per lifetime for girls between 9 and 18, adult and childhood pneumococcal vaccines, annual fitness and nutrition assessments through the Universal biokineticist and dietician networks, and travel vaccines including yellow fever, hepatitis A, rabies and meningococcal disease.

HospiCare gets the same list without the glaucoma test, the fitness assessment and the nutrition assessment, at a total value of R10 400 rather than R15 600.

Emergencies

• Unlimited emergency transport by road and air within South Africa, through Netcare 911 on 082 911, on every option. Netcare 911 will dispatch from another ambulance service if it has to, and CompCare covers necessary air lifts.
• Non-emergency transport must be authorised by Netcare 911 at the time or within 24 hours, failing which a 25% co-payment applies.
• In an emergency CompCare covers the emergency room, the hospital account, radiology, pathology, specialists, blood transfusions, oxygen and related costs. The facility or admin fee is not covered.
• Hospital pre-authorisation runs 24 hours a day on 0860 111 090. Planned admissions should be authorised at least 48 hours in advance.
• Netcare 911 operators, paramedics, nurses and doctors give medical advice and assistance 24 hours a day.
• A hospital-at-home benefit is run with Quromed for certain illnesses, on referral from your treating doctor and subject to pre-authorisation.
• International travel cover for emergency medical costs is provided through Universal Rewards. No limit, territory or exclusion list for that cover is published in the 2026 documents.

The 2026 benefit guide and option summaries are explicitly a summary. CompCare states that the registered rules of the Scheme prevail in any dispute and that the 2026 benefits and contributions are subject to formal approval by the Council for Medical Schemes. The following are simply not in the documents:

• The 2026 contribution increase percentage, for the range or for any single option.
• Membership numbers, beneficiary numbers, the solvency ratio, reserves or contribution income.
• The Scheme's Council for Medical Schemes registration number.
• Any mapping of the option names CompCare used in earlier years to the 2026 names. If you know your cover by an older name, ask the Scheme in writing which 2026 option you are on.
• The Annual Threshold amount on SuperCare Plus.
• The limit on non-PMB specialised medication for HospiCare and SuperCare Plus.
• Any limit, territorial scope or exclusion list for the Universal Rewards international travel cover.
• The list of hospitals in the Netcare and Mediclinic networks, the designated provider pharmacy list, the medicine formularies, the reference price list and the Universal Care approved lists of radiology and pathology codes.
• The CompCare rate itself, expressed in rand, for any procedure or consultation.
• Antenatal visit numbers on HospiCare.

You have to disclose in full any sickness or medical condition for which medical advice, diagnosis, care or treatment was recommended or received in the twelve months before you apply. What CompCare may then impose depends on your cover history:

• No medical scheme cover for more than 90 days before you apply: a general waiting period of 3 months and a condition-specific waiting period of 12 months on any pre-existing condition. CompCare states this applies to Prescribed Minimum Benefits as well.
• On a scheme for less than 24 months, applying within 3 months of leaving it: a condition-specific waiting period of 12 months, plus any unexpired waiting period your previous scheme had imposed. You keep entitlement to Prescribed Minimum Benefits.
• On a scheme for more than 24 months, applying within 3 months of leaving it: a general waiting period of 3 months only. You keep entitlement to Prescribed Minimum Benefits.

Late-joiner penalties

A late-joiner penalty applies to an applicant or adult dependant older than 35 at the date of application, based on the number of years they have not belonged to a registered South African medical scheme. It does not apply to anyone who has had unbroken cover, with no gap over three consecutive months, since 1 April 2001. The penalty is applied only to that person's share of the contribution and is permanent.

The band is worked out as A equals B minus 35 plus C, where B is your age when you apply and C is the number of years of creditable cover you can demonstrate. A 60-year-old with 10 years of creditable cover lands on 15 years and a 50% penalty. Dig out proof of every past membership before you apply.

• Instant cover. CompCare offers next-day cover at a pro-rata contribution regardless of the day of the month, through an online application or the Universal.one App, and says the application takes under 10 minutes. Once approved you get a membership number and digital card immediately.
• Join after January and you get less. All annual limits, including the savings account, are pro-rated from your date of registration to 31 December.
• You can change option only once a year, with effect from 1 January, in writing and within the period the Scheme notifies. You cannot change option mid-year.
• Employer groups may limit your choice. If you join through an employer, your options may be restricted to those agreed between you and the employer. SuperCare Plus is only available this way.
• Leaving with a spent savings account costs money. The savings account is advanced in full for the year. If you resign mid-year having used more than the pro-rata share, you owe the Scheme the difference. A positive balance is paid to you or transferred to your new scheme in the fifth month after resignation.
• Resignation needs one month's written notice unless your employment requires membership, in which case you need your employer's written consent.
• Late payment. If a contribution is more than three days late, the Scheme may suspend benefit payments for claims arising during the default, and may charge a fee and interest at its bankers' prime overdraft rate.
• Dependants of a deceased member keep membership with no new restrictions, limitations or waiting periods. Where children are orphaned, the eldest may be treated as the member.
• You must tell the Scheme within 30 days of any change of address, including the address for legal proceedings.

• No claim form is needed. Sign the account or invoice and send it in. Claims must reach the Scheme within four months of the date of treatment, and it is your responsibility to make sure they do, even when the provider submits electronically.
• How to send them. Email compcare@universal.co.za, post to Universal Healthcare Administrators, Private Bag X49, Rivonia, 2128, or submit through the Universal.one App. Put your name, membership number and contact number on the claim, legibly.
• Payment runs happen every two weeks, with a monthly statement of all transactions.
• Hospital pre-authorisation on 0860 111 090, 24 hours a day, at least 48 hours before a planned admission.
• Auxiliary services in hospital need their own authorisation number. Physiotherapy, dietetics and similar services are not covered by the hospital authorisation, and a 20% co-payment applies if you do not get a separate number.
• Specialist referrals. Get a GP referral letter, then request a "Spec Auth" from the call centre on 0861 222 777 or specauth@universal.co.za before the visit. You need the referral letter on the practice letterhead, your membership number, the dependant's name, your contact numbers, the intended date, and the specialist's name, practice number and contact details.
• Chronic medicine. Your doctor or pharmacist contacts Universal Care to apply. There is no form.
• Co-payments you pay yourself can be refunded to the Scheme by EFT, payroll deduction or debit order. If you have gap cover, check its rules first: some gap providers will not reimburse a co-payment you paid out of your savings account.

1. Lodge the complaint with Universal Healthcare Administrators, by phone on 0861 222 777 or by email to escalations@universal.co.za. The Escalations team will help immediately where it can. Any unresolved telephonic complaint, and every written complaint, gets a written response within 30 days, copied to the Fund Manager.
2. Escalate to the Fund Manager if you are not satisfied with the outcome. Send it to compcare@universal.co.za or ask the call centre agent to transfer you to the appropriate senior official. Every escalation must come with supporting evidence.
3. Refer a dispute to the disputes committee. The Principal Officer may refer a dispute between you and the Scheme to a disputes committee appointed by the Board of Trustees. You get at least 21 days' written notice of the meeting, and you have the right to be heard in person or through a representative.
4. Appeal to the Council for Medical Schemes. An appeal against the disputes committee's decision must be by affidavit and must reach the Council within three months of the date of that decision. Phone 0861 123 267 or email complaints@medicalschemes.com. You may contact the Council directly at any stage.

Suspected fraud, corruption, bribery or maladministration goes to the independent Vuvuzela Hotline, not to the Scheme: 080 111 4447 toll free, universal@thehotline.co.za, or a "Please call me" to 072 595 9139. Reports can be anonymous and the line runs 24 hours a day.

SelfCare Plus at R2 820 a month for a principal member, R2 820 for an adult dependant and R986 a child. There are no income bands, so everybody pays the same. It buys unlimited GP consultations with a R110 co-payment face to face, unlimited hospitalisation at Netcare or Mediclinic and a R3 372 savings account. What it does not buy is surgery: joint replacement, spinal fusion, back and neck surgery, reflux surgery, nasal surgery and arthroscopy are all excluded unless they qualify as Prescribed Minimum Benefits, and specialists are capped at two consultations a family a year up to R2 350.

It depends which option. On UltraCare Plus and ExecuCare Plus it means one thing and one thing only: you may use any private hospital instead of Netcare. Every other benefit, limit and co-payment is identical to the non-Plus version. It costs R1 844 a month more on UltraCare and R1 453 more on ExecuCare for a principal member. On SelfCare Plus, SaverCare Plus and SuperCare Plus, Plus is just part of the name and there is no non-Plus twin to compare it to.

If you chose to go there, you pay 35% of the hospital or facility account with a minimum of R8 220. On SelfCare Plus the 35% extends to all associated costs including specialist, radiology and pathology accounts, and no minimum is published. In a genuine emergency the rule does not apply the same way: go to the closest appropriate network hospital, and if none is nearby you may use the nearest available facility, with CompCare covering it until a transfer to a network hospital becomes possible. If the emergency team asks you where to go and you can answer, ask for the nearest network hospital.

Yes, on every option, and it is the most common way CompCare members lose money. Without a referral letter you pay a 35% co-payment on the specialist visit and on the related services such as pathology and radiology. You are also asked to notify the Scheme before the visit by requesting a "Spec Auth" on 0861 222 777 or at specauth@universal.co.za. There are exceptions: one gynaecologist visit a year for a woman over 16, one urologist visit a year for a man over 40, paediatrician visits for a child under 2, specialist visits during pregnancy, oncologist consultations under an approved oncology programme, ophthalmologists and orthodontists, and any case where multiple specialist visits have already been authorised. Once a specialist has seen you, they can refer you to another specialist without you going back to the GP, as long as the first visit was authorised.

Compare it with SaverCare Plus before you decide. HospiCare gives you unlimited hospitalisation at any Netcare hospital, R10 400 of preventative care and unlimited telephonic counselling, and nothing else. There is no savings account, no GP benefit, no dentistry and no optometry. Elective surgery carries a R15 600 deductible, and if the procedure costs less than R15 600 you pay the full cost of it yourself. Joint replacement, back and neck surgery, arthroscopy, reflux surgery and hearing aids are excluded, and cancer cover is Prescribed Minimum Benefits only. SaverCare Plus is R798 a month cheaper for a member, gives you any private hospital, a R7 896 savings account, a R5 272 insured day-to-day benefit and named per-procedure co-payments instead of the R15 600 deductible.

It is the stretch you fund out of your own pocket after your Annual Flexi Benefit runs out and before the Annual Threshold is reached, on UltraCare, UltraCare Plus, ExecuCare, ExecuCare Plus and SuperCare Plus. For a principal member it is R10 608 on UltraCare and UltraCare Plus, R5 200 on ExecuCare and ExecuCare Plus and R4 545 on SuperCare Plus. For an adult dependant it is R7 900, R3 120 and R6 136 respectively, which is the one place in the range where an adult dependant faces a bigger gap than the member. Only GP and specialist consultations, prescribed acute medicine, radiology and pathology accumulate towards the threshold on UltraCare and ExecuCare, so spending on dentistry or glasses does not shorten the gap.

On six options, yes, at the oncology designated service provider: unlimited at 100% of the CompCare rate on ExtraCare, UltraCare, UltraCare Plus, ExecuCare, ExecuCare Plus and SuperCare Plus, subject to pre-authorisation, protocols and the oncology formulary. On SelfCare Plus, SaverCare Plus and HospiCare, cancer cover is Prescribed Minimum Benefits only. Separately, the specialised medication that often drives a cancer bill has its own limits: PMB only on SelfCare Plus and SaverCare Plus, R192 400 a family on ExtraCare, R271 440 on UltraCare and R374 400 on ExecuCare, with a 25% co-payment everywhere except ExecuCare.

Yes, on the three options that have one. The Personal Medical Savings Account on SelfCare Plus, SaverCare Plus and SuperCare Plus is advanced in full on 1 January and unused money carries over for as long as you stay on an option with a savings account. It does not carry over into an option without one. Note the reverse risk: because the money is advanced, resigning mid-year after spending more than your pro-rata share means you owe the Scheme the difference. The Annual Flexi Benefit on SaverCare Plus, UltraCare and ExecuCare, and the Day-to-Day Benefit on ExtraCare, do not carry over at all.

It depends entirely on the option, and the range is the widest of any single procedure. On SelfCare Plus joint replacement is excluded outside Prescribed Minimum Benefits, and on HospiCare it is PMB only. On SaverCare Plus it is R30 000, on ExtraCare R26 000, on UltraCare and UltraCare Plus R4 160, and on ExecuCare, ExecuCare Plus and SuperCare Plus there is no co-payment. The prosthesis itself is limited separately: R34 940 on SaverCare Plus, R35 000 on ExtraCare, R42 120 on UltraCare and R43 370 on ExecuCare, all inside the overall family prosthesis limit.

If you have had no medical scheme cover for more than 90 days before applying, a general waiting period of 3 months and a condition-specific waiting period of 12 months on pre-existing conditions, and CompCare states that this applies to Prescribed Minimum Benefits too. If you were on a scheme for less than 24 months and apply within 3 months of leaving, a 12-month condition-specific waiting period plus any unexpired waiting period from the previous scheme, with PMBs preserved. If you were on a scheme for more than 24 months and apply within 3 months of leaving, a 3-month general waiting period only, with PMBs preserved. You must disclose every condition for which you received or were recommended advice, diagnosis, care or treatment in the previous twelve months.

It applies to anyone over 35 at application who has gaps in their medical scheme history, and it is permanent. The bands are 5% of contribution for 1 to 4 years without cover, 25% for 5 to 14 years, 50% for 15 to 24 years and 75% for 25 years or more. It is calculated only on that person's share of the contribution. You are exempt if you have had unbroken cover, with no gap longer than three consecutive months, since 1 April 2001. The band is worked out from your age minus 35, minus the years of creditable cover you can prove, so gather proof of every past membership before you apply.

Four steps. Phone 0861 222 777 or email escalations@universal.co.za, and Universal Healthcare's Escalations team must respond in writing within 30 days, copying the Fund Manager. If you are not satisfied, escalate to the Fund Manager at compcare@universal.co.za, with supporting evidence. If it is still unresolved, the Principal Officer may refer it to a disputes committee, which must give you at least 21 days' notice and let you be heard in person or through a representative. Finally you may appeal to the Council for Medical Schemes, by affidavit, within three months of the disputes committee's decision, on 0861 123 267 or complaints@medicalschemes.com. You may also approach the Council directly at any stage.