Necesse Network in 2020
This comprehensive product provides quality cover through an extensive network of private hospitals and healthcare providers for medical expenses incurred in and out of hospital.
| Gross monthly income | R601 - R11 000 | R11 001 and more | ||
| Principal member |  | R2 208 | R2 574 | |
| Dependant | | R1 722 | R2 016 | |
| Child dependant <21 years |  | R972 | R1 116 | |
Core benefits
Chronic illness/PMB
- 100% of the cost for 270 PMB and 26 chronic conditions (DSPs, formularies, networks, protocols and pre-authorisation apply)
- Unlimited cover for trauma that necessitates hospitalisation
Emergency transport
Netcare 911
Transport by road or air within South Africa
100% of the MT – unlimited
Emergency unit services and non-network consultations
80% of the MT
- Member = R1 100 | Member+ = R2 250
Outpatient emergency unit services, non-network doctors’ visits, medicine and services rendered by a non-network medical doctor and radiology requested by a non-network medical doctor
100% of the MT
- Pathology at Lancet/PathCare
Hospitalisation
100% of the MT – unlimited
131 quality private network hospitals
Confinement (childbirth)
PMB – 100% of the MT
Non-PMB – R26 300 per confinement for an elective caesarean section
Home delivery – R13 000 per event
Physiotherapy and occupational therapy
In hospital – R9 850 per family per year
Physiotherapy on request of the attending medical doctor
Specialised radiology
In and out of hospital
Services requested by a specialist on referral by a network GP
- MRI and CT imaging (subject to pre-authorisation) and angiography
100% of the MT – R16 500 per family per year
Standard radiology, pathology (Lancet/PathCare only) and medical technologist services
In hospital – 100% of the MT
R30 500 per family per year
Internally implanted prostheses benefits
PMB only – 100% of the cost
R23 000 per beneficiary per year
- EVARS prosthesis
- Vascular/cardiac prosthesis
- Health-essential functional prosthesis
Oncology
PMB only – 100% of the MT
Organ transplants
PMB
100% of the cost
Cornea implants – R28 800 per implant per year
Sub-acute care and private nursing services
As an alternative to hospitalisation – R22 300 per family per year
Clinical technologist services
In hospital – R22 300 per family per year
Added insured benefits
These benefits are provided in addition to other insured benefits, may be subject to available day-to-day benefits and must be requested by a Necesse network GP unless otherwise indicated.
Women's health
- A pap smear
- A mammogram for women 40 years and older
- Women over 50 years have access to one bone mineral density test
Enhanced maternity benefits
- Pregnancy and baby programme
- 2 consultations per beneficiary at a gynaecologist, if referred by a Necesse network GP and pre-authorised
- Two 2D ultrasound scans per beneficiary
Routine screening and immunisation benefits
- One blood glucose and one cholesterol test
- HIV testing, counselling and support by a Necesse network GP
- A tetanus vaccine
- A flu vaccination by a Necesse network GP or at a network pharmacy (payable from over-the-counter medicine benefit)
Supporting wellness
- Back treatment at a Document Based Care facility
- Chronic Care programme
Men's health
- A prostate test (PSA level) for men 40 years and older
HealthPrint
Medihelp members get free access to this online health and wellness programme designed to add value based on their health profile through programmes such as a pregnancy and baby programme and discounts at selected partners
Day-to-day benefits
GP services within the Necesse network
9 consultations per beneficiary per year
Specialist care
Subject to referral by a Necesse network GP, clinical protocols and pre-authorisation, which includes one follow-up consultation.
Member = R3 200 per year
Member+ = R4 500 per year
Conservative dental benefits
Subject to DRC managed care protocols and services rendered by a DRC network dentist
Medicine
- Acute medicine and PMB chronic medicine
Necesse GP network, pharmacy network and formularies apply - Self-medication obtained from a network pharmacy – 100% of the MMAP (R100 per event or R290 per beneficiary per year)
Optometry
PPN network and benefits per beneficiary per 24-month cycle apply
- 1 composite examination
- Spectacles or contact lenses
- Spectacles: R550 for a frame/lens enhancements and 1 pair of standard clear Aquity lenses
- R730 for contact lenses
Standard radiology and pathology
100% of the MT
- List of item codes and protocols apply
- DSP for pathology is Lancet or PathCare
Physiotherapy and occupational therapy
On request of a Necesse network GP
Member = R2 050 per year
Member+ = R3 200 per year
Medical appliances
In and out of hospital – 100% of the MT
- Wheelchairs – R4 700 per family in a 3-year cycle
- CPAP apparatus – R9 700 per beneficiary per 24-month cycle (out of hospital)
Important:
This is only a summary of the available benefits. Please consult the registered Medihelp Rules for more information and details of services that are excluded from benefits. In case of a dispute, the Rules of Medihelp will apply (subject to approval by the Council for Medical Schemes).
Benefits may be subject to pre-authorisation and protocols. Benefits are paid at 100% of the MT. The Necesse network GP must be the starting point for all services and must refer Necesse patients for radiology, pathology and treatment by specialists.
Abbreviations:
AOL-Overall annual limit | CDL-Chronic Diseases List | CPAP-Continuous positive airway pressure | CT-Computerised tomography | DRC-Dental Risk Company | DSP-Designated service provider | EMS-Emergency medical services | EVARS-Endovascular aortic replacement surgery | GP-General practitioner | MMAP-Maximum Medical Aid Price | MRI-Magnetic resonance imaging | MT-Medihelp tariff paid by Medihelp for benefits which can include a contracted tariff or the single exit price | PMB-Prescribed minimum benefits | PPN-Preferred Provider Negotiators
