| ||||
|---|---|---|---|---|
| Network | Non-network | |||
| Principal member |  | R1 626 | R2 082 | |
| Dependant | | R1 338 | R1 716 | |
| Child dependant <26 years |  | R492 | R630 | |
You only pay for 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. The monthly contribution does not take any employer subsidy into account.
Core benefits
Chronic illness/PMB
- 100% of the cost for 270 PMB and 26 chronic conditions (DSPs, formulary, networks, protocols and pre-authorisation apply)
- Unlimited cover for trauma that necessitates hospitalisation
Emergency transport
Netcare 911
In country of residence
RSA, Lesotho, Swaziland, Mozambique, Namibia & Botswana – unlimited
Outside country of residence
Transport by road R2 050 and by air
R13 700 per case
Hospitalisation
100% of the MT
Non-network: any hospital
Network: 119 network hospitals
Specialised radiology
In and out of hospital
- MRI and CT imaging – 100% of the MT
Unlimited (see deductibles) - Angiography – 100% of the MT
Unlimited
Psychiatric treatment
R19 300 per beneficiary per year
(maximum R29 300 per family per year)
Oncology
In and out of hospital
- PMB – 100% of the MT
- Non-PMB – R210 800 per family per year
Confinement (childbirth)
- In hospital – 100% of the MT
- Home delivery – R13 000 per event
Organ transplants
100% of the cost
- Cornea implants – R28 800 per implant
Other core benefits
Renal dialysis, oxygen, prostatectomy, hospice, sub-acute care and private nursing services as an alternative to hospitalisation
Post-hospital care
R1 800 per member and R2 500 per family per year for speech therapy, occuational therapy and physiotherapy for up to 30 days after discharge
Prostheses benefits
- Health-essential functional prosthesis: R23 000
- Hip, knee and shoulder replacements (non-PMB):
- Acute injuries where replacement is the only treatment option -
Hospitalisation: 100% of the MT
Prosthesis: Health-essential functional prosthesis benefit applies (wear and tear: no benefits) - Intra-ocular lenses – R4 150 per lens, 2 lenses per beneficiary per year, health-essential functional prosthesis benefit applies
- EVARS prosthesis – R34 600
- Vascular/cardiac prosthesis – R34 600
- Prosthesis with reconstructive or restorative surgery and external breast prostheses (in and out of hospital) –
R4 250 per family per year
Added insured benefits
Women's health
- A mammogram for women 40 years and older (per 2-year cycle)
- A pap smear (per 3-year cycle)
Enhanced maternity benefits
- Pregnancy and baby programme
- 12 ante- & postnatal consultations
- Two 2D ultrasound scans per family
Child benefits
- Two additional GP or specialist visits (babies under 1 year)
- Standard child immunisations for children younger than 7 years
Routine screening and immunisation
- A combo test (blood glucose, cholesterol, BMI & blood pressure measurement)/individual blood glucose or cholesterol test
- HIV testing
- A tetanus vaccine
- A flu vaccination
- Two HPV vaccinations for girls and boys between 10-14 years or three between 15-26 years
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
Men's health
- A prostate test (PSA level) for men 40 years and older
Supporting wellness
- One dietician consultation per registered HealthPrint member if a BMI test result indicates a BMI higher than 30
- Back treatment at a Document Based Care facility
- Chronic Care programme
Over 50s
- One bone mineral density test for women over 50 years
- A Pneumovax vaccine in a 5-year cycle per person over 55 years
- An FOBT test for people over 50 years
Day-to-day benefits
Insured day-to-day benefits
GP and specialist consultations, physiotherapy, acute medicine and self-medication, including visits to emergency units
Member = R1 200 per year
Member+ = R2 400 per year
Medicine
PMB chronic medicine
Non-network – 100% of the MHRP
Network – 100% of the MHRP (DSP and formulary apply)
Dentistry
DRC network applies
100% of the MT for dental procedures under conscious sedation in the dentist’s chair (sedation cost) for the removal of impacted teeth only (3rd molars)
Dentist’s account – item codes apply
External prostheses and medical appliances
In and out of hospital
- Benefit per family per 3-year cycle:
- Artificial eyes – R4 700
- Speech and hearing aids – R4 700
- Wheelchairs – R4 700
- Artificial limbs – R4 700
- CPAP apparatus – R9 700 per beneficiary per 24-month cycle
Additional information
Deductibles
Visiting network service providers, following the correct pre-authorisation process and negotiating tariffs with your doctor are just some of the ways you can manage or reduce out-of-pocket medical expenses.
Procedure-specific deductibles
(Payable by the member)
- Spinal column surgery – R11 600 per admission
- Endoscopic procedures – gastroscopy, colonoscopy, arthroscopy and sigmoidoscopy
In a day clinic – R2 100, in hospital – R3 200 - Specialised radiology – R1 650 per examination
- Dental procedures under general anaesthesia during hospitalisation
Removal of impacted teeth (3rd molars, item codes apply on dentist’s account) and extensive dental treatment for children <5 years (dentist’s account for member’s account) – R3 300 per admission
Pre-authorisation is important
The following services and procedures are paid at 100% of the Medihelp tariff if pre-authorised:
- All planned hospital admissions (protocols and case management apply)
- Oxygen for out-of-hospital use (protocols and case management apply)
- Dental procedures under conscious sedation (sedation cost) in the dentist’s chair (managed care protocols apply)
Should these services not be pre-authorised, an 80% benefit will apply
Oncology
Subject to pre-authorisation and registration on the Medihelp Oncology Programme, use of the designated service provider and treatment protocols to avoid deductibles. The Medihelp Oncology Reference Price applies to oncology medicine.
Prime 1 Network
- Members of Prime 1 Network should use network hospitals for all planned admissions. A 65% benefit applies when an out-of-network hospital is used by choice.
- 40% of the Medihelp Reference Price is paid if PMB chronic medicine is obtained outside the formulary and/or DSP on the network option. It is advisable for chronic medicine users to rather choose the alternative non-network option.
Emergency transport services (Netcare 911)
In and outside the country of residence (air and road transport) should be pre-authorised to qualify for the applicable benefit. If not pre-authorised, 50% of the benefit applies except in the case of emergency medical conditions.
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).
- Certain added insured benefits are not available if you have been registered for a PMB condition as the treatment is no longer considered as preventive care and may be linked to a specific age/gender/item code. Benefits are paid at 100% of the MT.
- Doctors’ consultations are paid from available day-to-day benefits.
- Subject to pre-authorisation and/or protocols.
- Generic medicine = 100% of MMAP | Original medicine – no generic available = 80% of MT | Choose original medicine – generic is available = 70% of MMAP
Abbreviations:
AOL-Overall annual limit | BMI-Body mass index | 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 | FOBT-Faecal occult blood test | GP-General practitioner | HPV-Human papilloma virus | MHRP-Medihelp Reference Price | 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
