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
