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
R24 400 per beneficiary per year (maximum R33 500 per family per year)
Oncology
In and out of hospital
- PMB – 100% of the MT
- Non-PMB – R231 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, occupational therapy and physiotherapy for up to 30 days after discharge
Prostheses benefits
- Health-essential functional prosthesis: R61 900
- 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)
- Acute injuries where replacement is the only treatment option –
- Intra-ocular lenses – R4 150 per lens, 2 lenses per beneficiary per year, health essential functional prosthesis benefit applies
- Hip, knee and shoulder replacements (non-PMB):
- EVARS prosthesis – R130 600
- Vascular/cardiac prosthesis – R55 900
- Prosthesis with reconstructive or restorative surgery (in and out of hospital) – R9 600 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
Day-to-day benefits
15% savings account
- Credit facility equalling 12 months’ savings contributions is available at the beginning of each financial year
- Unclaimed savings funds will accumulate interest and be added to your available savings for the next year
- Flexible payment option to include or exclude in-hospital co-payments and shortfalls
Optometry
Savings account
Medicine
PMB chronic medicine
Non-network option – 100% of the MHRP
Network option – 100% of the MHRP (DSP and formulary apply)
Dentistry
DRC network applies
- Conservative and specialised dental services – savings account
- 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
Child care benefits
R2 000 per family per year
A special benefit for GP consultations for children 2 to < 12 years old is activated after depletion of the savings account
External prostheses and medical appliances
In and out of hospital
- Savings account
- Hyperbaric oxygen treatment – R630 per family per year
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 – R10 400 per admission
- Endoscopic procedures – gastroscopy, colonoscopy, arthroscopy and sigmoidoscopy
In a day clinic – R2 750, in hospital – R3 850 - 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 payable from savings account) – R3 300 per admission
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 2 Network
- Members of Prime 2 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.
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)
- Specialised dental services
- Crowns and bridges
- Periodontal treatment (conservative non-surgical therapy only)
Subject to pre-authorisation and treatment plan
Should these services not be pre-authorised, an 80% benefit will apply
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.
Abbreviations
AOL-Overall annual limit | BMI-Body mass index | CDL-Chronic Diseases List | 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 | 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
