Dimension Prime 2 | 2014 Medical aid

Dimension Prime 2

The Dimension Prime range of benefit options offers members a choice between non-network options, or a significantly reduced contribution when choosing the network version of the option.  Dimension Prime network options are ideal for the healthy and offer a national footprint of excellent hospitals and specialists.  The available benefits do not differ between the standard Dimension Prime benefit options and the network options.  Members of the network options must use the network hospitals, designated specialists and a restricted designated services provider (DSP) for chronic PMB medicine. A 60% co-payment applies for voluntary use of a non-DSP.


Notification: Chronic PMB medicine

 

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Monthly contribution (network option)

 
Member Subscription
Principal member R1 320
(R288 savings contribution included per month and R3 456 per year)
Dependant R1 086
(R240 savings contribution included per month and R2 880 per year)
Child dependant younger than 26 years R390
(R84 savings contribution included per month and R1 008 per year) (you pay for maximum two children younger than 18 years*)

* You pay for maximum two children younger than 18 years – after which child dependant rates will apply from the beginning of the year following the year in which they turn 18, until they are 26 years old.

Monthly contribution

 
Member Subscription
Principal member R1 656
(R366 savings contribution included per month and R4 392 per year)
Dependant R1 356
(R300 savings contribution included per month and R3 600 per year)
Child dependant younger than 26 years R492
(R108 savings contribution included per month and R1 296 per year) (you pay for maximum two children younger than 18 years*)

* You pay for maximum two children younger than 18 years – after which child dependant rates will apply from the beginning of the year following the year in which they turn 18, until they are 26 years old.

Preventive care

 
PREGNANCY AND BABY BENEFITS
Pregnancy benefits are subject to participation in the mom-2-be programme:
  • 12 Pregnancy consultations & two 2D sonars per family per year
  • Two 2D scans per family per year
  • Two consultations per beneficiary in baby’s first year
  • Standard immunisation for children younger than 7 years

HEALTH TESTS 
(One test per beneficiary per year)
  • Blood sugar test – pathology (item codes 4050/4057)
  • Cholesterol test – pathology (item code 4027)
  • Pap smear – pathology (item codes 4566/4559)
  • 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)
  • HIV test (15 years and older)
  • Bone densitometry scan – radiology imaging only (item codes 3604/50120)
    (females 50 years and older)

IMMUNISATIONS (vaccine only)
  • Flu vaccination - 1 per beneficiary per year
  • Tetanus vaccine - 1 per beneficiary per year
  • HPV vaccine - females between 10 and 26 years
    (3 injections during the course of a year, once per lifetime)

BACK TREATMENT PROGRAMME
Back treatment programme – 1 programme per beneficiary per year at a Medihelp-appointed facility within reasonable proximity, as a prerequisite for spinal column surgery (subject to protocols and pre-authorisation)

Major medical benefits

 
  Description Benefit

DIAGNOSIS, TREATMENT AND CARE COSTS OF 270 PMB AND 26 CHRONIC CONDITIONS ON THE 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/non-protocol use

BENEFITS FOR MAJOR 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

EMERGENCY TRANSPORT SERVICES (ER24)
RSA, Lesotho, Swaziland, Mozambique and Namibia
Subject to pre-authorisation

  • In beneficiary’s country of residence
    • Transport by road
    • Transport by air
100% of the contracted tariff
Unlimited
50% co-payment if not pre-authorised
  • Outside beneficiary’s country of residence
    • Transport by road
100% of the cost
R1 520 per case
50% co-payment if not pre-authorised
  • Transport by air
100% of the cost
R9 930 per case
50% co-payment if not pre-authorised
24-HOUR HELPLINE AND TRAUMA COUNSELLING (ER24) Phone 084 124

HOSPITALISATION (state and private hospitals and day clinics)
Subject to pre-authorisation, protocols and case management

  • Intensive and high-care wards
  • Ward accommodation
  • Theatre fees
  • Treatment and ward medicine
  • Consultations, surgery and anaesthesia
100% of the UPFS/contracted/scheme tariff/medicine price/cost
Procedure-specific co-payments may apply (non-PMB cases)
Unlimited
20% co-payment if not pre-authorised

Dimension Prime 2 Network option:
30% co-payment for voluntary non-network admissions
PROCEDURE-SPECIFIC CO-PAYMENTS See co-payments
PROSTHESES See prostheses

CONFINEMENT (childbirth)
Subject to pre-authorisation, protocols and case management

100% of the UPFS/contracted/scheme tariff/medicine price/cost
Unlimited
20% co-payment if not pre-authorised

HOME DELIVERY
Subject to pre-authorisation

  • Professional nursing fees
  • Equipment
  • Material and medicine
100% of the contracted/scheme tariff/medicine price
R9 500 per event
20% co-payment if not pre-authorised

STANDARD RADIOLOGY, PATHOLOGY AND MEDICAL TECHNOLOGIST SERVICES
In hospital
Subject to clinical protocols

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

SPECIALISED RADIOLOGY
In and out of hospital
On request of a specialist and subject to clinical protocols

  • MRI and CT imaging
    (Subject to pre-authorisation)
  • Angiography
100% of the contracted/scheme tariff/medicine price/cost
R15 500 per family per year

PHYSIOTHERAPY, OCCUPATIONAL AND SPEECH THERAPY, DIETICIAN SERVICES, AUDIOMETRY, PODIATRY, MASSAGE, ORTHOPTIC, CHIROPRACTIC, HOMEOPATHIC, HERBAL AND NATUROPATHIC, OSTEOPATHIC AND BIOKINETIC SERVICES
In hospital

100% of the contracted/scheme tariff/medicine price/cost
Unlimited
OXYGEN
In hospital
100% of the contracted/scheme tariff/cost
Unlimited

NEUROSTIMULATORS
Subject to pre-authorisation and clinical protocols

  • Device and components
100% of the scheme tariff/cost
R80 000 per beneficiary per year

RENAL DIALYSIS
In and out of hospital
Subject to pre-authorisation and clinical protocols

100% of the contracted/scheme tariff
Unlimited

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

100% of the contracted/scheme tariff/medicine price/cost
R270 per admission

PSYCHIATRIC TREATMENT OF A MENTAL HEALTH CONDITION
Subject to pre-authorisation, services rendered in an approved/network hospital/facility and prescribed by a medical doctor

  • Professional services rendered in and out of hospital by a psychiatrist
  • General ward accommodation
  • Medicine supplied during the period of the treatment in the institution
  • Outpatient consultations
100% of the contracted/scheme tariff/medicine price/cost
R17 580 per beneficiary per year
(maximum R24 070 per family per year)

20% co-payment if not pre-authorised

ONCOLOGY
PMB cases

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)
100% of the contracted/scheme tariff/medicine price/cost
Limited to PMB cases at DSP
ICON standard protocols
Co-payments apply for voluntary non-network services (10%) and/or deviating from protocol (20%)
  • Bone marrow/stem cell transplants
100% of the scheme tariff/cost
Subject to protocols

Non-PMB cases
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)
Savings account

HOSPICE SERVICES AND SUB-ACUTE CARE FACILITIES AS AN ALTERNATIVE TO HOSPITALISATION
Subject to pre-authorisation, and services rendered in an approved facility and prescribed by a medical doctor

100% of the contracted/scheme tariff/medicine price/cost
Unlimited
20% co-payment if not pre-authorised

PRIVATE NURSING AS AN ALTERNATIVE TO HOSPITALISATION
Subject to pre-authorisation
(Excluding general day-to-day care)

100% of the contracted/scheme tariff/medicine price/cost
20% co-payment if not pre-authorised

UPFS - Uniform Patient Fee Schedule
MRI - Magnetic resonance imaging
EMS - Emergency medical services
CDL - Chronic Diseases List
DSP - Designated service providers
CT - Computerised tomography
PMB - Prescribed Minimum Benefits
TTO - To take out (medicine)
ICON - Independent Clinical Oncology Network
MORP - Medihelp Oncology Reference Price

Procedure-specific co-payments

 
Description Co-payment
All hospital admissions are subject to pre-authorisation, protocols and case management Covered at:
100% of the UPFS/contracted/scheme tariff/medicine price/cost
20% co-payment if not pre-authorised

Dimension Prime 2 Network option:
30% co-payment on voluntary non-network admissions
HYSTERECTOMY R1 500 per admission
ENDOMETRIAL ABLATION R1 500 per admission
FUNCTIONAL NASAL SURGERY R1 500 per admission
REFLUX SURGERY R3 000 per admission
NECK AND BACK FUSIONS R8 000 per admission
REMOVAL OF SKIN LESIONS R1 000 per admission
MYRINGOTOMY R1 000 per admission
ENDOSCOPIC PROCEDURES
  • In hospital
    • Gastrointestinal
    • Colonoscopy
    • Arthroscopy
    • Sigmoidoscopy
    • Renal endoscopy
    • Endoscopic procedures of prostate
    • Laparoscopy
R2 350 per admission
  •  In the doctor's rooms
 No co-payment

DENTAL PROCEDURES UNDER GENERAL ANAESTHESIA
In hospital
Subject to pre-authorisation and Denis managed care protocols
For the removal of impacted teeth and extensive dental treatment for children younger than 5 years only

R1 600 per admission

100% of the Medihelp Dental Tariff

Only for removal of impacted teeth (item codes 8941/8943/8945 on dentist’s account) and extensive dental treatment for children younger than 5 years – once per lifetime

Dentist’s services: savings account

Internally implanted prostheses

 
Description Benefit
All hospital admissions are subject to pre-authorisation, protocols and case management Covered at:
100% of the UPFS/contracted/scheme tariff/medicine price/cost
20% co-payment if not pre-authorised
The member is liable for the difference in cost should PMB spinal, hip, knee and cardiac prostheses not be obtained from the DSP

Dimension Prime 2 Network option:
30% co-payment on voluntary non-network admissions
INTERNALLY IMPLANTED PROSTHESIS
  • EVARS prosthesis

R93 400 per beneficiary per year
  • Vascular/cardiac prosthesis
R40 000 per beneficiary per year
  • Health-essential functional prosthesis
    • Intra-ocular lenses
R44 300 per beneficiary per year
Sub-limit:
2 lenses per beneficiary per year
R3 070 per lens
  • Hip, knee and shoulder replacements
    For the hospital account and prosthesis components
Scheme only pays R14 100 per admission for hospital account and prosthesis components (combined)
  • Prosthesis with reconstructive or restorative surgery and external breast prostheses
    In and out of hospital
R7 000 per family per year

UPFS – Uniform Patient Fee Schedule
ICPS – Improved Clinical Pathway Services
DSP – Designated service provider

Day-to-day benefits

 
Description Benefit
GPs, SPECIALISTS AND EMERGENCY UNITS
  • Treatment (medical and surgical services, anaesthesia as well as material and medicines used during the service)
100% of the contracted/scheme tariff/medicine price/cost
Savings account
  • Consultations and follow-up consultations
PHYSIOTHERAPY
Treatment and material
CLINICAL PSYCHOLOGY AND PSYCHIATRIC NURSING
OCCUPATIONAL AND SPEECH THERAPY, DIETICIAN SERVICES, AUDIOMETRY, PODIATRY, MASSAGE, ORTHOPTIC, CHIROPRACTIC, HOMEOPATHIC, HERBAL AND NATUROPATHIC, OSTEOPATHIC AND BIOKINETIC SERVICES
MEDICINE
Medicine obtained in the Medihelp Preferred Pharmacy Network and prescribed/dispensed by a medical doctor
  • Acute medicine (including medicine dispensed at an emergency unit and over-the-counter (OTC) medicine, immunisations, contraceptives and homeopathic, herbal, naturopathic and osteopathic medicine)
100% of the scheme tariff/medicine price (MMAP)
Savings account
  • Chronic non-PMB medicine
    Subject to pre-authorisation and registration on Medihelp’s chronic medicine management programme
  • Chronic PMB medicine
    Subject to pre-authorisation and registration on Medihelp’s PMB medicine management programme
    Dimension Prime Network range: 
    Restricted DSP – 60% co-payment for voluntary use of non-DSP
Notification: Chronic PMB medicine
100% of the MRP
Unlimited
OPTOMETRY
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 24-month cycle per beneficiary 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 24-month cycle per beneficiary from the date of the first service
  • Lenses
    (one pair of standard clear Aquity lenses)
Single vision or bifocal lenses per beneficiary per 24-month cycle from the date of the first service
  • Contact lenses
R950 (only PPN provider) per beneficiary per 24-month cycle from the date of the first service
OXYGEN
Out of hospital
Subject to pre-authorisation, clinical protocols and services prescribed by a medical doctor
100% of the contracted/scheme tariff/cost
Unlimited
20% co-payment if not pre-authorised
DENTAL SERVICES
Subject to Denis managed care protocols
Conservative dental services
  • Routine check-ups
100% of the Medihelp Dental Tariff
Savings account
2 per beneficiary per year
(once in 6 months)
  • Oral hygiene
    • 1 fluoride treatment for children younger than 13 years only
    • Fissure sealants for children younger than 16 years only
100% of the Medihelp Dental Tariff
Savings account
2 scale and polish treatments per beneficiary per year (once in 6 months)
  • Fillings
    (Treatment plans and X-rays may be requested for multiple fillings)
100% of the Medihelp Dental Tariff
Savings account
1 filling per tooth in 365 days
  • Tooth extractions and root canal treatment in the dentist’s chair
100% of the Medihelp Dental Tariff
Savings account
  • Laughing gas (in the dentist’s chair)
  • Dental procedures under conscious sedation in the dentist’s chair
    (sedation cost)
    Subject to pre-authorisation and managed care protocols
100% of the Medihelp Dental Tariff
Removal of impacted teeth only
(Dentist’s account only for item codes 8941/8943/8945)
20% co-payment if not pre-authorised
  • Plastic dentures
100% of the Medihelp Dental Tariff
Savings account
  • X-rays
    • Intra-oral X-rays
100% of the Medihelp Dental Tariff
Savings account
  • Extra-oral X-rays
100% of the Medihelp Dental Tariff
Savings account
1 per beneficiary in a 3-year period, from the date of the first service
Specialised dental services
Subject to pre-authorisation and Denis managed care protocols
  • Partial metal frame dentures
100% of the Medihelp Dental Tariff
Savings account
  • Maxillofacial surgery and oral pathology
    • Surgery in the dentist’s chair
      Benefits for temporomandibular joint (TMJ) therapy are limited to non-surgical interventions/treatment
100% of the Medihelp Dental Tariff
Savings account
20% co-payment if not pre-authorised
  • Crowns and bridges
    Subject to pre-authorisation
100% of the Medihelp Dental Tariff
Savings account
1 crown per family per year, once per tooth in a 5-year period, from the date of the first service
20% co-payment if not pre-authorised
  • Implants
    Subject to pre-authorisation
100% of the Medihelp Dental Tariff
Savings account
20% co-payment if not pre-authorised
  • Orthodontic treatment
    Subject to pre-authorisation and orthodontic needs analysis
    (Only one beneficiary per family may begin orthodontic treatment per calendar year)
100% of the Medihelp Dental Tariff
Savings account
For beneficiaries younger than 18 years per lifetime
Payment from date of authorisation only
  • Periodontal treatment
    Subject to pre-authorisation and registration on the Perio Programme Conservative non-surgical therapy only
100% of the Medihelp Dental Tariff
Savings account
20% co-payment if not pre-authorised
PATHOLOGY AND MEDICAL TECHNOLOGIST SERVICES
Out of hospital
Subject to clinical protocols and requested by a medical doctor
100% of the contracted/scheme tariff/cost
Savings account
STANDARD RADIOLOGY
Out of hospital
Subject to clinical protocols and requested by a medical doctor or chiropractor (black and white X-rays only)
100% of the contracted/scheme tariff/medicine price/cost
Savings account
EXTERNAL PROSTHESES, MEDICAL, SURGICAL AND ORTHOPAEDIC APPLIANCES
Services in and out of hospital and prescribed by a medical doctor
  • Artificial eyes, speech and hearing aids
100% of the scheme tariff/cost
R3 400 per family per 3-year cycle
  • Artificial limbs and wheelchairs
  • Incontinence products/supplies
  • Hyperbaric oxygen treatment
  • Other appliances
100% of the the scheme tariff/cost
Savings account
  • Stoma components and urine bags
100% of the scheme tariff/cost
Unlimited

MRP - Medihelp Reference Price
MMAP - Maximum Medical Aid Price
GP - General practitioner
PMB - Prescribed Minimum Benefits
PPN - Preferred Provider Negotiators
DSP - Designated service provider

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. Please note that the Rules for 2014 will be released in due course. Phone Medihelp on 086 0100 678 if you have any enquiries about the Rules of Medihelp.