Necesse
2014
 

Monthly contribution

 
Member Subscription
*Gross monthly income
R7 500 and less R7 501 – R11 000 R11 001 and more
Principal member R1 002 R1 182 R1 374
Dependant R792 R924 R1 074
Child dependant <21 years R426 R516 R594

* If the gross monthly income (before deductions) is more than R11 001, no proof of income is required.

Preventive care

 
HEALTH TESTS (one test per beneficiary per year and requested by a Necesse network general practitioner)
  • Blood sugar test – pathology (item code 4057)
  • Cholesterol test – pathology (item code 4027)
  • Pap smear – pathology (item code 4566)
  • Mammogram – radiology imaging only (item codes 3605/39175/34100/34101)
    (females 40 years and older)
  • Prostate test – pathology (item code 4519)
    (40 years and older)
  • Bone densitometry scan – radiology imaging only (item code 50120)
    (females 50 years and older)

IMMUNISATIONS
(vaccine only and requested by a Necesse network general practitioner)
  • Flu vaccination - 1 per beneficiary per year
  • Tetanus vaccine - 1 per beneficiary per year

Major medical benefits

 
Description Benefit
HOSPITALISATION IN A NETWORK HOSPITAL
Subject to pre-authorisation, case management and clinical protocols
  • Intensive care and high-care wards
  • Ward accommodation
  • Theatre fees
  • Ward medicine
  • Consultations, surgery and anaesthesia
100% of the UPFS/contracted/scheme tariff/medicine price/cost
Unlimited
20% co-payment if not pre-authorised, or for non-emergency admission or voluntary admission to a non-network hospital
APPLICABLE PRESCRIPTION MEDICINE DISPENSED AND CHARGED BY THE HOSPITAL ON DISCHARGE FROM HOSPITAL (TTO)
(Excluding chronic medicine)
100% of the contracted/scheme tariff/medicine price/cost
R270 per admission
PHYSIOTHERAPY AND OCCUPATIONAL THERAPY
In hospital
100% of the scheme tariff/cost
R7 140 per family per year
STANDARD RADIOLOGY, PATHOLOGY AND MEDICAL TECHNOLOGIST SERVICES
In hospital
Interventional procedures performed by a radiologist
Pathology services should be rendered by Lancet or PathCare
100% of the contracted/scheme tariff/medicine price/cost
R22 000 per family per year
SPECIALISED RADIOLOGY
In and out of hospital
Only services requested by a specialist on referral by a network GP and subject to clinical protocols
  • MRI and CT-imaging
    (Subject to pre-authorisation)
  • Angiography
100% of the contracted/scheme tariff/medicine price/cost
R11 900 per family per year
OXYGEN
In hospital
100% of the contracted/scheme tariff
CLINICAL TECHNOLOGIST SERVICES
In hospital
100% of the scheme tariff/cost
R16 050 per family per year
DENTAL PROCEDURES UNDER GENERAL ANAESTHESIA
In a network hospital and prescribed by a Denis network dental practitioner Subject to pre-authorisation and Denis managed care protocols
100% of the Medihelp Dental Tariff
Only PMB services and extensive dental treatment for children younger than 5 years – once per lifetime
20% co-payment if not pre-authorised or in case of voluntary admission to a non-network hospital
CONFINEMENT (childbirth)
Subject to pre-authorisation and clinical protocols
Non-PMB cases
  • Hospitalisation
  • Midwifery and confinement/delivery
  • Gynaecologist and anaesthetist services
  • Post-natal services
100% of the contracted tariff/medicine price/cost
R19 000 per confinement for an elective caesarean section
20% co-payment if not pre-authorised or in case of voluntary admission to a non-network hospital
PMB cases
  • Hospitalisation
  • Midwifery and confinement/delivery
  • Gynaecologist and anaesthetist services
  • Post-natal services
100% of the contracted tariff/medicine price/cost
Unlimited
20% co-payment if not pre-authorised or in case of voluntary admission to a non-network hospital
HOME DELIVERY
Subject to pre-authorisation and clinical protocols
  • Professional nursing fees
  • Equipment
  • Material and medicine
100% of the scheme tariff/medicine price/cost
R9 500 per event
20% co-payment if not pre-authorised
SUB-ACUTE CARE AND PRIVATE NURSING SERVICES AS AN ALTERNATIVE TO HOSPITALISATION
Subject to pre-authorisation, and services prescribed by a medical doctor
(Excluding general day-to-day care)
100% of the contracted/scheme tariff/medicine price/ cost
R16 050 per family per year
20% co-payment if not pre-authorised
TTO - To take out (medicine)
GP - General practitioner
MRI - Magnetic resonance imaging
CT - Computerised tomography
PMB - Prescribed Minimum Benefits
UPFS - Uniform Patient Fee Schedule

Trauma

 
Description Benefit
BENEFITS FOR TRAUMA THAT NECESSITATES HOSPITALISATION IN THE CASE OF:
  • Motor vehicle accidents
  • Stab wounds
  • Gunshot wounds
  • Head trauma
  • Burns
  • Near drowning
Subject to authorisation, PMB protocols and case management
100% of the cost
Unlimited
POST-EXPOSURE PROPHYLAXIS

Prescribed Minimum Benefits (PMB)

 
Description Benefit
DIAGNOSIS, TREATMENT AND CARE COSTS OF 270 PMB AND 26 CHRONIC CONDITIONS ON THE CHRONIC DISEASES LIST (CDL)
Subject to protocols, pre-authorisation and DSPs
100% of the contracted tariff/cost
Unlimited
Co-payments may apply in case of voluntary non-DSP use/protocol deviation
ONCOLOGY (PMB ONLY)
Subject to pre-authorisation and registration on the Medihelp Oncology Management Programme
  • Radiotherapy, including brachytherapy
  • Chemotherapy and associated adjuvant medicine (medicine subject to the MORP)
  • Bone marrow/stem cell transplants
    (subject to protocols)
100% of the contracted/scheme tariff/medicine price/cost
Limited to PMB cases at DSPs
ICON standard protocol
Co-payments apply in case of voluntary non-network services (10%) and/or treatment outside protocol (25%)
HIV/AIDS (PMB ONLY)
  • Antiretroviral therapy and treatment by a DSP (Optipharm)
100% of the contracted/scheme tariff
RENAL DIALYSIS (PMB ONLY)
Subject to pre-authorisation and clinical protocols
In and out of hospital
  • Acute dialysis
  • Chronic/peritoneal dialysis
100% of the contracted/scheme tariff/cost
PSYCHIATRIC TREATMENT OF A MENTAL HEALTH CONDITION (PMB ONLY)
Subject to pre-authorisation, and services must be rendered in an approved hospital/facility and must be requested by a Necesse network GP or a specialist on referral by a network GP
  • Professional services rendered by a psychiatrist in and out of hospital
  • General ward accommodation
  • Medicine supplied during the treatment in the institution
  • Outpatient visits
100% of the contracted/scheme tariff/medicine price/cost
MAXILLOFACIAL SURGERY DUE TO TRAUMA-RELATED INJURIES (PMB ONLY)
Subject to pre-authorisation and clinical protocols
100% of the contracted/scheme tariff/cost
PROSTHESES (PMB ONLY)
Subject to pre-authorisation, clinical and PMB protocols
  • Internally implanted prostheses
    • EVARS prostheses
    • Vascular/cardiac prostheses
    • Health-essential functional prostheses
      • Intra-ocular lenses
    • Prosthesis with reconstructive or restorative surgery
100% of the scheme tariff
  • External prostheses, including breast prostheses
100% of the scheme tariff/cost
R7 140 per family per year
MEDICAL, SURGICAL AND ORTHOPAEDIC APPLIANCES (PMB ONLY)
Services in hospital and prescribed by a medical doctor

PMB - Prescribed Minimum Benefits
CDL - Chronic Diseases List
MORP - Medihelp Oncology Reference Price
DSP - Designated service providers
ICON – Independent Clinical Oncology Network

Emergency medical services (EMS)

 
Description Benefit
EMERGENCY TRANSPORT SERVICES
Provided and pre-authorised by ER24

Transport by road or air within the borders of South Africa only
100% of the contracted tariff
Unlimited
50% co-payment if not pre-authorised
24-HOUR HELPLINE AND TRAUMA COUNSELLING (ER24) Phone 084 124
EMERGENCY UNITS AND NON-NETWORK CONSULTATIONS 100% of the cost
  • Outpatient emergency unit and non-network consultations
  • Medicine and services rendered by a non-network medical doctor
80% of the scheme tariff
R820 per single member per year
R1 650 per family per year
  • Pathology requested by a medical doctor according to the list of pathology codes and rendered by Lancet/PathCare
100% of the contracted tariff
  • Facility fee and radiology
For member’s account

Day-to-day benefits

 
Description Benefit
GP SERVICES WITHIN THE NECESSE NETWORK
  • Consultations
  • Medical and surgical services as well as anaesthetics
  • Material and discretionary medicine used during services
100% of the contracted/scheme tariff/medicine price
9 consultations per beneficiary per year, thereafter only consultations for PMB conditions
(Subject to pre-authorisation)
PREGNANCY
Subject to pre-authorisation and clinical protocols
  • Pre- and post-natal care provided by a Necesse network GP
  • Midwife services by a registered nursing practitioner
100% of the scheme tariff
Unlimited
20% co-payment if not pre-authorised
  • Gynaecologist services
    Subject to referral by a Necesse network GP
100% of the scheme tariff
2 consultations per beneficiary in addition to the specialist limit
20% co-payment if not on referral or not pre-authorised
  • Sonars (2D) by a medical doctor
100% of the scheme tariff
Two 2D sonars per beneficiary per year
SPECIALIST CARE
Subject to referral by a Necesse network GP and pre-authorisation, which includes one follow-up consultation:
  • Specialist consultations
  • Surgical and non-surgical procedures
  • Diagnostic endoscopic procedures performed in the specialist’s rooms
  • Standard radiology and pathology
    (Lancet/PathCare) requested by a specialist
  • Interventional procedures performed by radiologists
  • Acute medicine prescribed by a specialist
    Must be obtained from a network pharmacy
100% of the contracted/scheme tariff/medicine price/cost
R2 370 per single member or
R3 370 per family per year
20% co-payment if not referred by a Necesse network GP
  • Authorised chronic PMB medicine prescribed by a specialist on referral by a Necesse network GP is subject to pre-authorisation
    Must be obtained from a network pharmacy
100% of the Necesse PMB formulary
Co-payments may apply in case of voluntary non-network pharmacy use and deviation from the formulary
MEDICINE
  • Acute medicine
    • Dispensed by a dispensing Necesse network GP (included in the consultation fee)
100% of the contracted tariff
  • Only formulary medicine obtained from a network pharmacy prescribed by a Necesse network GP or Denis network dentist
100% of the medicine price (MMAP) according to the Necesse acute medicine/dental formularies
  • Over-the-counter (OTC) medicine obtained from a network pharmacy
100% of the medicine price (MMAP)
R70 per event
R210 per beneficiary per year
  • Authorised chronic PMB medicine obtained from a network pharmacy Subject to pre-authorisation, protocols and formulary
100% of the medicine price according to the Necesse chronic medicine formulary
Unlimited
PHYSIOTHERAPY AND OCCUPATIONAL THERAPY
Out of hospital
Must be requested by a Necesse network GP
100% of the scheme tariff/cost
M = R1 540 per year
M+ = R2 370 per year
OXYGEN
Out of hospital
Prescribed by a medical doctor and subject to pre-authorisation and clinical protocols
100% of the contracted/scheme tariff
20% co-payment if not pre-authorised
STANDARD RADIOLOGY (X-RAYS)
Subject to Scheme-approved codes and referred by a Necesse network GP
  • Black and white X-rays and soft-tissue ultrasound scans only as per the Scheme’s clinical protocols
100% of the contracted/scheme tariff
PATHOLOGY
Subject to a list of pathology codes and tests only, done by Lancet/PathCare on request of a Necesse network GP
100% of the contracted tariff/cost
Co-payments apply if services are not rendered by Lancet/PathCare
OPTOMETRY
Benefits are subject to pre-authorisation by PPN and services should be obtained from a PPN provider:
  • Optometric examinations
    1 comprehensive consultation, including refraction test, tonometry and visual field test
100% of the contracted tariff
1 examination per beneficiary per 24-month cycle from the date of the first service
  • Spectacles or contact lenses
    Benefits are limited to either spectacles or contact lenses:
    • Spectacles
      • Frames and/or lens enhancements
R200 (PPN frame) per beneficiary per 24-month cycle from the date of the first service
  • Lenses (one pair of standard clear Aquity lenses)
Single vision or bifocal or multifocal lenses per beneficiary per 24-month cycle from the date of the first service
  • Contact lenses
R395 per beneficiary per 24-month cycle from the date of the first service
DENTAL SERVICES
Subject to Denis managed care protocols and services rendered by a Denis network dentist
Conservative services
  • Routine check-ups
100% of the Medihelp Dental Tariff
1 per beneficiary per year
  • Fillings
    (X-rays and treatment plans may be requested for multiple fillings)
100% of the Medihelp Dental Tariff
4 fillings per beneficiary, 1 filling per tooth in 365 days
Amalgam fillings (item codes 8341/8342/8343/8344) and resin restorations in anterior teeth (item codes 8351/8352/8353/8354)
  • Oral hygiene
    Only children younger than 16 years
    • 1 fluoride treatment per beneficiary per year
    • Fissure sealants
100% of the Medihelp Dental Tariff
1 polish (item code 8155) or 1 scale and polish (item code 8159) treatment per year
  • Tooth extractions
100% of the Medihelp Dental Tariff
  • Root canal treatment in the dentist’s chair
    Subject to pre-authorisation
100% of the Medihelp Dental Tariff
2 teeth per beneficiary per year
  • Plastic dentures
    Including associated laboratory costs
80% of the Medihelp Dental Tariff
1 set of plastic dentures (upper and lower jaw) per family (21 years and older) in a 2-year period, from the date of the first service
  • Laughing gas (in the dentist’s chair)
100% of the Medihelp Dental Tariff
  • Dental procedures under conscious sedation in the dentist’s chair
    Subject to pre-authorisation
100% of the Medihelp Dental Tariff
Extensive dental treatment only
  • X-rays
    • Intra-oral
100% of the Medihelp Dental Tariff
4 per beneficiary per year
  • Extra-oral
100% of the Medihelp Dental Tariff
1 per beneficiary in a 3-year period, from the date of the first service
  • Medicine
    Only formulary medicine obtained from a network pharmacy prescribed by a Denis network dentist
100% of the medicine price (MMAP) according to the acute medicine/dental formularies

GP - General practitioner
PMB - Prescribed Minimum Benefits
MMAP - Maximum Medical Aid Price

Proof of income

 

If no proof of income can be provided, your subscription will be based on the highest income category.

Source Acceptable proof of income
Full-time employment
Basic salary, overtime, commission
Bonuses (all types, e.g. 13th cheque, production bonus etc.)
Allowances (all types, e.g. car/travelling, cell phone etc.)
Fringe benefits (e.g. company car)
Past three months' official pay slips
Most recent tax assessment – ITA 34
IRP5 of previous tax year
Past three months’ commission and bank statements* indicating commission payments
An official appointment letter by the employer indicating gross monthly income – not older than 3 months
Investments
Interest
Dividends
Rental income
Letter of auditor/accountant/tax adviser
Most recent tax assessment – ITA 34
IT3(a) and past three months’ bank statements*
Rental income – rental agreement and past three months’ bank statements*
Self-employed
Income from vocation/profession
Total income from business and irregular income
Most recent tax assessment – ITA 34
Letter of auditor/accountant/tax adviser
Past three months’ commission and bank statements*
Trusts
Income from trusts
Most recent tax assessment – ITA 34
Unemployed
Individuals who earn no income from a vocation/profession/business or receive an allowance
UIF payments and bank statements*
Income of the person paying the subscriptions/ allowance
Pensions and annuities
Income from pensions or annuities
Most recent tax assessment – ITA 34
Past three months’ pension payment advices and other proof
Full-time students at a tertiary institution
(Members without dependants)
Notice/letter on an official letterhead of the tertiary institution where the member is registered as a full-time student
Copy of member’s student card for the particular year
* Only official bank statements indicating the account holder’s initials and surname will be accepted. Please indicate clearly which payments/deposits refer to your income.

This is a summary of the available benefits. In the event of a dispute the registered Rules of Medihelp will apply, subject to approval by the Registrar of Medical Schemes. If a beneficiary joins during the course of a financial year, the benefits are calculated pro rata according to the remaining number of months per year. Phone Medihelp on 086 0100 678 if you have any enquiries about the Rules of Medihelp.