medihelp products 2012

Dimension Elite

Your health determines your quality of life. Maintaining your health and making provision for the best care when you or your loved ones need it, is important. That's why it is essential to invest in your future by partnering with a medical scheme that offers you access to the best quality private healthcare.

What makes the Dimension Elite benefit option unique?

  • Day-to-day benefits - ample separately insured benefits
  • Major medical benefits - unlimited treatment (medical and surgical services, anaesthesia as well as material and medicines used during the rendering of a service) by GPs and specialists
  • Dentistry benefits
  • Optometry benefits
  • Dependent children under 26 pay subscriptions for child dependants
  • Preventative care - health and benefit booster

R2,394 / pm

I want to join – member application Network Provider list Online calculator

Monthly contribution

 
Member Subscription
Principal member R2,394
Adult dependant R2,238
Child dependant younger than 26 years R648

Preventative care - Health and benefit booster

 
Immunisations*
Flu vaccination
1 per beneficiary per year
Tetanus vaccine
1 per beneficiary per year
Subject to protocols
HPV vaccine
Subject to protocols
(Females between 10 and 26 years)
Health tests*
Pap smear – pathology (item code 4566)
1 per beneficiary per year
Blood sugar test – pathology (item code 4057)
1 per beneficiary per year
(40 years and older)
Cholesterol test – pathology (item code 4027)
1 per beneficiary per year
(40 years and older)
Standard mammogram – radiology
(item code 3605/39175/34100/34101)
1 per beneficiary per year
(Females 40 years and older)
Prostate test – pathology (item code 4519)
1 per beneficiary per year
(40 years and older)
HIV rapid test (in addition to PMB)
1 per beneficiary per year
Subject to protocols
(15 years and older)
Additional benefits
Pregnancy consultations
12 per family per year
Paediatric consultations
2 visits in baby’s first year
Back treatment programme at a Medihelp appointed facility as a prerequisite for spinal column surgery
Subject to protocols and pre-approval
1 programme per beneficiary per year

* Benefits are provided at 100% of the contracted/scheme tariff and do not include the consultation fee, which will be paid from the available day-to-day benefits where applicable.

Major medical benefits

 
Description Benefit

HOSPITALISATION
(government and private hospitals and day clinics)

Subject to pre-registration, pre-authorisation, protocols and case management

  • Intensive and high care wards
  • Ward accommodation
  • Theatre fees
  • Visits, treatment and ward medicine
  • Surgery and anaesthesia

100% of the contracted/scheme tariff/medicine price
Procedure-specific co-payments may apply (non-PMB cases)

Unlimited
20% co-payment in case of no pre-authorisation
ORGAN TRANSPLANT
CONFINEMENT
HYSTERECTOMY
ENDOSCOPIC PROCEDURES
  • During hospitalisation
100% of the contracted /scheme tariff
R2,000 co-payment per admission
  • In the doctor’s rooms
100% of the scheme tariff
Unlimited

ONCOLOGY (SAOC NETWORK – ONCOELITE PROTOCOL)
Subject to pre-authorisation

  • Surgery and hospitalisation
  • Chemotherapy and radiotherapy (PMB cases)
100% of the scheme tariff/cost
Unlimited
  • Chemotherapy and radiotherapy (non-PMB cases)
    During and not during hospitalisation
100% of the scheme tariff/medicine price
R18,940 per beneficiary per year
DENTAL PROCEDURES UNDER GENERAL ANAESTHESIA
Subject to Denis protocols and pre-authorisation
  • Hospitalisation
  • General anaesthesia

100% of the Medihelp Dental Tariff

R600 co-payment per admission

20% co-payment in case of no pre-authorisation
GENERAL RADIOLOGY AND PATHOLOGY
During hospitalisation 		100% of the scheme tariff
Unlimited
PHYSIOTHERAPY, OCCUPATIONAL AND SPEECH THERAPY, DIETICIAN SERVICES, AUDIOMETRY, PODIATRY, MASSAGE, ORTHOPTIC, CHIROPRACTIC, HOMEOPATHIC, HERBAL AND NATUROPATHIC, OSTEOPATHIC AND BIOKINETIC SERVICES
During hospitalisation 		100% of the scheme tariff/cost
Unlimited
OXYGEN
During hospitalisation 		100% of the scheme tariff/cost
Unlimited
DIALYSIS
During and not during hospitalisation
Subject to pre-authorisation 		100% of the scheme tariff
Unlimited
TECHNOLOGIST SERVICES
During and not during hospitalisation 		100% of the scheme tariff
Unlimited

APPLICABLE PRESCRIPTION MEDICINE DISPENSED AND CHARGED BY THE HOSPITAL ON DISCHARGE FROM THE HOSPITAL (TTO)

Excluding chronic medicine

 100% of the medicine price
R260 per admission
NECK AND BACK FUSIONS (non-PMB cases)
Subject to protocols and pre-authorisation 		100% of the contracted/scheme tariff
Unlimited
R6,230 co-payment per admission
CIRCUMCISION OR HYMENECTOMY 100% of the contracted/scheme tariff
Unlimited
R1,130 co-payment per admission

INTERNALLY IMPLANTED PROSTHESES (non-PMB cases)

 

  • EVARS prosthesis
    Subject to pre-authorisation

 

 

100% of the scheme tariff/cost
R83,140 per beneficiary per year

  • Vascular/cardiac prosthesis
100% of the scheme tariff/cost
R35,600 per beneficiary per year
  • Health-essential functional prosthesis
    Subject to pre-authorisation

 

 

  • Intra-ocular lenses

100% of the scheme tariff/cost
R39,470 per beneficiary per year

Sub-limit:
100% of the scheme tariff/cost
2 lenses per beneficiary per year

R2,760 per lens

  • Hip, knee and shoulder replacements
    Hospitalisation and prosthesis component
    Subject to pre-authorisation
100% of the scheme tariff/cost
R12,580 per admission
  • Prosthesis with reconstructive or restorative surgery
    Subject to pre-authorisation 
    During and not during hospitalisation  
100% of the scheme tariff/cost
R6,230 per family per year
SPECIALISED RADIOLOGY
Services rendered during and not during hospitalisation
  • MRI and CT scanning
    Subject to pre-authorisation 
  • Angiogram
100% of the scheme tariff
R20,860 per family per year
PSYCHIATRIC TREATMENT OF A MENTAL HEALTH CONDITION
Subject to pre-authorisation
  • Professional psychiatric services rendered during and not during hospitalisation by a psychiatrist
  • General ward accommodation
  • Electroconvulsive therapy
  • Medicine supplied during the period of treatment in the institution

100% of the contracted/scheme tariff/medicine price
R600 co-payment per admission (non-PMB cases)
R22,680 per beneficiary per year (maximum R31,380 per family per year)

20% co-payment in case of no pre-authorisation 

PRIVATE NURSING

Subject to pre-authorisation and as an alternative to hospitalisation

100% of the contracted/scheme tariff/medicine price
Unlimited
HOSPICE SERVICES AND SUB-ACUTE CARE FACILITIES

Subject to pre-authorisation and as an alternative to hospitalisation

100% of the contracted/scheme tariff/medicine price
Unlimited

20% co-payment in case of no pre-authorisation

Major medical benefits – trauma recovery (PMB cases)

 
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 pre-authorisation and case management

100% of the cost

Unlimited - in accordance with PMB regulations
POST-EXPOSURE PROPHYLAXIS (Optipharm)

Major medical benefits – prescribed minimum benefits (PMB)

 
Description Benefit
DIAGNOSIS, TREATMENT AND CARE COSTS OF 270 PMB AND 26 CHRONIC CONDITIONS ON THE CDL, INCLUDING OUTPATIENT TREATMENT
Subject to protocols, pre-authorisation and preferred providers (where applicable) 		100% of the cost
Unlimited - in accordance with PMB regulations 
Co-payments may apply

Emergency medical services

 
Description Benefit
EMERGENCY TRANSPORT SERVICES (NETCARE 911)
Transport by road or air within the borders of the RSA, Lesotho, Swaziland, Mozambique and Namibia (residents of these countries)

100% of the contracted tariff

Unlimited
Outside these borders:
  • Transport by road

100% of the cost
R1,360 per case

  • Transport by air
100% of the cost
R8,840 per case
BLOOD TRANSFUSION SERVICES AND THE TRANSPORT OF BLOOD AND BLOOD PRODUCTS 100% of the cost   
Unlimited
24-HOUR HELPLINE AND RAPE CRISIS CENTRE (NETCARE 911) Phone 082 911 for advice in a medical emergency

Day-to-day benefits

 
Description Benefit
GENERAL MEDICAL PRACTITIONERS, MEDICAL SPECIALISTS AND EMERGENCY UNITS
  • Treatment (medical and surgical services, anaesthesia as well as material and medicines used during the rendering of a service)
100% of the scheme tariff/medicine price
Unlimited
  • Consultations and follow-up
100% of the scheme tariff/cost
R1,850 per single member per year
R3,550 per family per year
CLINICAL PSYCHOLOGISTS AND PSYCHIATRIC NURSES
Services rendered during and not during hospitalisation
PHYSIOTHERAPISTS
Treatment and material
OCCUPATIONAL AND SPEECH THERAPY, DIETICIAN SERVICES, AUDIOMETRY, PODIATRY, MASSAGE, ORTHOPTIC, CHIROPRACTIC, HOMEOPATHIC, HERBAL AND NATUROPATHIC, OSTEOPATHIC AND BIOKINETIC SERVICES
MEDICINE
Medicine dispensed by the Medihelp Preferred Pharmacy Network
  • Acute medicine (including medicine dispensed at an emergency unit and self-medication, oral contraceptives, intra-uterine devices and homeopathic, herbal, naturopathic and osteopathic medicine)
80% of the medicine price
R2,800 per single member per year
R5,300 per family per year
  • Authorised chronic medicine
 80% of the medicine price
R2,720 per single member per year
R4,240 per family per year
  • Authorised chronic PMB medicine
100% of the medicine price
Unlimited
Co-payments may apply
OPTOMETRY
Benefits are subject to pre-authorisation by PPN and services should be obtained from a PPN provider
  • Optometric examinations
Benefits are available per 24-month cycle per beneficiary:

1 comprehensive consultation, including refraction test, tonometry and visual fields test
  • Spectacles and contact lenses
    Benefits are limited to either spectables or contact lenses:
  • Spectacles:
  • Frame and/or lens enhancements

 

 

R700
  • Lenses
    One pair of standard high-quality clear lenses

Clear single vision lenses or

Clear Aquity bifocal lenses or

Clear Aquity multifocal lenses

  • Contact lenses
R1,510
DENTAL SERVICES
All benefits are subject to clinical protocols determined by Denis
  • Routine check-ups
100% of the Medihelp Dental Tariff
2 per beneficiary per year
  • Oral hygiene
    Fluoride treatments for children only
100% of the Medihelp Dental Tariff
2 scale and polish treatments per beneficiary per year
  • Fillings
    Treatment plan and X-rays may be required for multiple fillings
100% of the Medihelp Dental Tariff
1 filling per tooth per 365-day cycle
  • Tooth extractions and root canal treatment in the dentist’s chair
100% of the Medihelp Dental Tariff
  • Laughing gas (in the dentist’s chair)

 100% of the Medihelp Dental Tariff
  • Dental procedures under conscious sedation in the dentist's chair (sedation cost) 
    Subject to pre-authorisation and protocols
100% of the Medihelp Dental Tariff
Extensive dental treatments only
  • Plastic dentures
100% of the Medihelp Dental Tariff
1 set (upper and lower jaw) per beneficiary in a 4-year cycle
  • Specialised dental services
    All specialised dentistry should be pre-authorised
  • Partial metal frame dentures
100% of the Medihelp Dental Tariff
2 partial frames (upper and lower jaw) per beneficiary in a 5-year cycle
  • Maxillofacial surgery and oral pathology
  • Surgery in the dentist's chair 
    Benefits for temporomandibular joint (TMJ) therapy are limited to non-surgical interventions/treatments
100% of the Medihelp Dental Tariff
  • Crowns and bridges
100% of the Medihelp Dental Tariff
2 crowns per family per year, once per tooth in a 5-year cycle
  • Implants
For member's account
  • Orthodontic treatment
    Fixed braces – only one beneficiary per family may begin orthodontic treatment per calendar year
100% of the Medihelp Dental Tariff
R8,000 per beneficiary younger than 18 years per lifetime
  • Periodontal treatment
    Subject to registration on the Perio Programme

              Conservative, non-surgical therapy only

100% of the Medihelp Dental Tariff
  • X-rays
  • Intra-oral X-rays
100% of the Medihelp Dental Tariff
  • Extra-oral X-rays
1 per beneficiary in a 3-year cycle
PATHOLOGY
Excluding services requested by naturopaths, herbalists and homeopaths 		100% of the scheme tariff
R1,900 per family per year
GENERAL RADIOLOGY 100% of the scheme tariff
R1,900 per family per year
MEDICAL, SURGICAL AND ORTHOPAEDIC APPLIANCES
Services rendered during and not during hospitalisation:
  • Artificial eyes, speech and hearing aids
100% of the scheme tariff/cost
R5,350 per beneficiary per 3-year cycle
  • Artificial limbs and wheelchairs
100% of the scheme tariff/cost
R4,280 per beneficiary per 3-year cycle
  • Other appliances, including hyperbaric oxygen treatment
100% of the scheme tariff/cost
R410 per beneficiary per year
  • Stoma components and urine bags
100% of the scheme tariff/cost
Unlimited

OXYGEN

Subject to pre-authorisation

 100% of the scheme tariff/cost
20% co-payment in case of no pre-authorisation
Rules and exclusions

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 (limits) are calculated pro rata according to the remaining number of months per year. Click here