Products 2016

our 2016 medical aid products

 
Necesse 2016
from R396 per month
 
An income-based network option which provides access to a quality network of providers. It’s the ideal option for full-time tertiary students and corporate clients.

Monthly contribution

 
Member Subscription
*Gross monthly income
R0 - R400
(Full-time student)
R401 - R5 000 R5 001 - R7 000 R7 001 - R11 000 R11 001 and more
Principal member R396 R1 266 R1 320 R1 494 R1 740
Dependant R396 R1 002 R1 056 R1 164 R1 356
Child dependant <21 years R396 R540 R594 R654 R750

* If the gross monthly income (before deductions) is more than R11 001, no proof of income is required.
 

Preventive care*

 
Our preventive care benefits are designed to enable you to pick up on and prevent potential health problems, keeping you healthy.

HEALTH TESTS (One test per beneficiary per year requested by a Necesse network general practitioner)
  • 1 blood glucose test (pathology: 4057)
  • 1 cholesterol test (pathology: 4027)
  • 1 pap smear (pathology: 4566)
  • 1 mammogram for women > 40 years (radiology imaging: 3605/39175/34100/34101)
  • 1 prostate test for men > 40 years (pathology: 4519)
  • 1 bone density test for women > 50 years (radiology imaging: 3604/50120)
IMMUNISATION (One immunisation per beneficiary per year requested by a Necesse network GP)
  • 1 flu vaccine
  • 1 tetanus vaccine

BACK TREATMENT PROGRAMME
One Document-Based Care (DBC) back treatment programme per beneficiary per year at a DBC facility (Subject to protocols and pre-authorisation)

HEALTHPRINT WELLNESS PROGRAMME 

HealthPrint is an online wellness programme that displays the results of your health assessment tests on the site. You can also:

  • View, update and share your health information via the site
  • Add your activity tracker and view your performance
  • View your benefits used and check what healthcare benefits you have available
  • Join the Medihelp MultiSport club for runners and cyclists and qualify for discounts on gear and events, and receive a free Medihelp branded sports bag
  • Join the programme for pregnant women or for moms with young children and access a wealth of relevant health information and added value from selected HealthPrint partners.
Join HealthPrint in three easy steps:    
HealthPrint - wellness programme
* Subject to available day-to-day benefits.

Core benefits

 
  Description Benefit
Essential Cover

DIAGNOSIS, TREATMENT AND CARE COSTS OF 270 PMB AND 26 CHRONIC CONDITIONS ON THE CHRONIC DISEASES LIST (CDL)
Subject to protocols, pre-authorisation and DSPs

100% of the cost
Unlimited
ONCOLOGY*
Subject to pre-authorisation, DSP (ICON), protocols and registration on the Medihelp Oncology Management Programme (PMB)
  • Radiotherapy
  • Brachytherapy
  • Chemotherapy and associated adjuvant medicine (medicine subject to the MORP)
  • Bone marrow/stem cell transplants
100% of the cost
HIV/AIDS (PMB ONLY)
  • Antiretroviral therapy and treatment by a DSP (Dis-Chem Direct)
100% of the cost
RENAL DIALYSIS (PMB ONLY)
Subject to pre-authorisation and clinical protocols
In and out of hospital
  • Acute dialysis
  • Chronic/peritoneal dialysis
100% of the cost
PSYCHIATRIC TREATMENT OF A MENTAL HEALTH CONDITION (PMB ONLY)
Subject to pre-authorisation, and services must be rendered in an approved network hospital/facility and must be requested by a Necesse network GP or a specialist on referral by a network GP
  • Professional services rendered by a psychiatrist in and out of hospital
  • General ward accommodation
  • Medicine supplied during the period of treatment in the facility
  • Outpatient consultations
100% of the cost
MAXILLOFACIAL SURGERY DUE TO TRAUMA-RELATED INJURIES (PMB ONLY)
Subject to pre-authorisation and clinical protocols
100% of the cost
PROSTHESES (PMB ONLY)
Subject to pre-authorisation, clinical and PMB protocols
The member is liable for the difference in cost should PMB prostheses not be obtained from the DSP
  • Internally implanted prosthesis
    • EVARS prosthesis
    • Vascular/cardiac prosthesis
    • Health-essential functional prosthesis
      • Intra-ocular lenses
    • Prosthesis with reconstructive or restorative surgery
100% of the cost
  • External prostheses (in hospital), including breast prostheses (in and out of hospital)
100% of the cost
R8 060 per family per year
MEDICAL, SURGICAL AND ORTHOPAEDIC APPLIANCES (PMB ONLY)
Services in hospital and prescribed by a medical doctor
  • CPAP apparatus
100% of the cost
R7 950 per beneficiary in a
24-month cycle
ORGAN TRANSPLANTS (PMB ONLY)
Subject to pre-authorisation and clinical protocols
100% of the cost
Unlimited
  • Cornea implants (PMB)
100% of the cost
R23 350 per case per year
Trauma

BENEFITS FOR 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

EMS EMERGENCY TRANSPORT SERVICES
Provided and pre-authorised by ER24
Transport by road or air within the borders of South Africa
Subject to pre-authorisation
100% of the MT
24-HOUR HELPLINE AND TRAUMA COUNSELLING (ER24) Phone 084 124
EMERGENCY UNITS AND NON-NETWORK CONSULTATIONS
  • PMB-related emergencies (see definition in “explanation of terms”)
100% of the MT
  • Outpatient emergency unit services and non-network consultations
  • Medicine and services rendered by a non-network medical doctor
80% of the MT
M= R930 per year
M+= R1 870 per year
  • Pathology requested by a medical doctor
    Pathology codes and DSP (Lancet/PathCare) apply
100% of the MT
  • Facility fee and radiology
This benefit is not covered by this option
HOSPITALISATION IN A NETWORK HOSPITAL
Subject to pre-authorisation, case management and clinical protocols
  • Intensive care and high-care wards
  • Ward accommodation
  • Theatre fees
  • Ward medicine
  • Consultations, surgery and anaesthesia
100% of the MT
Unlimited
APPLICABLE PRESCRIPTION MEDICINE DISPENSED AND CHARGED BY THE HOSPITAL ON DISCHARGE FROM HOSPITAL (TTO)
(Excluding PMB chronic medicine)
100% of the MT
R310 per admission
PHYSIOTHERAPY AND OCCUPATIONAL THERAPY
In hospital
100% of the MT
R8 060 per family per year
STANDARD RADIOLOGY, PATHOLOGY AND MEDICAL TECHNOLOGIST SERVICES
In hospital
Interventional procedures performed by a radiologist, including material
Pathology codes and DSP (Lancet/PathCare) apply
100% of the MT
R24 850 per family per year
SPECIALISED RADIOLOGY
In and out of hospital
Only services requested by a specialist on referral by a network GP and subject to clinical protocols
  • MRI and CT imaging (subject to pre-authorisation)
  • Angiography
100% of the MT
R13 400 per family per year
OXYGEN
In hospital
100% of the MT
CLINICAL TECHNOLOGIST SERVICES
In hospital
100% of the MT
R18 150 per family per year
DENTAL PROCEDURES UNDER GENERAL ANAESTHESIA
In a network hospital and prescribed by a Denis network dentist
Subject to pre-authorisation and Denis managed care protocols
100% of the MT
Only PMB services and extensive dental treatment for children younger than 5 years – once per lifetime
CONFINEMENT (childbirth)
Subject to pre-authorisation and clinical protocols
Non-PMB cases
  • Hospitalisation
  • Midwifery and confinement/delivery
  • Gynaecologist and anaesthetist services
  • Post-natal services
100% of the MT
R21 450 per confinement for an elective caesarean section
PMB cases
Services rendered by a specialist on the Necesse specialist network, on referral by a network GP
  • Hospitalisation
  • Midwifery and confinement/delivery
  • Gynaecologist and anaesthetist services
  • Post-natal services
100% of the cost
Unlimited
HOME DELIVERY
Subject to pre-authorisation and clinical protocols
  • Professional nursing fees
  • Equipment
  • Material and medicine
100% of the MT
R10 750 per event
SUB-ACUTE CARE AND PRIVATE NURSING SERVICES AS AN ALTERNATIVE TO HOSPITALISATION
Subject to pre-authorisation, and services prescribed by a medical doctor (excluding general day-to-day care)
100% of the MT
R18 126 per family per year
CDL - Chronic Diseases List
DSP - Designated service provider
GP - General practitioner
ICON - Independent Clinical Oncology Network
MORP - Medihelp Oncology Reference Price
PMB  - Prescribed minimum  benefits 
CPAP  - Continuous positive airway pressure
TTO  - To take out (medicine)
- Member
MT  - Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price
CT  - Computerised tomography
MRI  - Magnetic resonance imaging
*Oncology: 96% of all oncology cases qualify for prescribed minimum benefits (PMB), which Medihelp will cover at 100% of the cost in terms of the Act, provided that oncology is rendered by oncologists within the Independent Clinical Oncology Network (ICON) according to their protocols. Oncology outside the ICON or that deviates from the protocols is subject to deductibles. Should oncology not qualify for PMB, members will be allowed to upgrade to the Medihelp Plus benefit option (conditions apply).
An emergency medical condition means any sudden and unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide such treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy. An emergency medical condition must be certified as such by a medical practitioner. Emergencies qualify for PMB and must therefore also be registered for PMB (see also “PMB”).
Prescribed minimum benefits (PMB) are paid for 26 chronic conditions on the CDL and 270 diagnoses with their treatments as published in the Regulations of the Medical Schemes Act, 1998 (Act No 131 of 1998). In terms of these Regulations, medical schemes are compelled to grant benefits for the diagnosis, treatment and care costs of any of these conditions as well as emergency medical conditions (that meet the published definition) without imposing any limits. PMB are subject to pre-authorisation, protocols, and the utilisation of designated service providers, where applicable, e.g. the ICON network for cancer treatment. Benefits for PMB services are first funded from the related day-to-day benefits.

Day-to-day benefits

 
Description Benefit
GP SERVICES WITHIN THE NECESSE NETWORK
  • Consultations
  • Medical and surgical services as well as anaesthesia
  • Material and discretionary medicine used during services
100% of the MT
9 consultations per beneficiary per year
PREGNANCY
  • Pre- and post-natal care provided by a Necesse network GP
  • Midwife services provided by a registered nursing practitioner for pre- and post-natal care, subject to pre-authorisation
100% of the MT
Unlimited
  • Gynaecologist services
    Subject to referral by a Necesse network GP and pre-authorisation
100% of the MT
2 consultations per beneficiary in addition to the specialist care benefit
  • Sonars (2D)
100% of the MT
Two 2D sonars per beneficiary per year
SPECIALIST CARE
Subject to referral by a Necesse network GP and pre-authorisation, which includes one follow-up consultation:
  • Specialist consultations
  • Surgical and non-surgical procedures
  • Diagnostic endoscopic procedures performed in the specialist’s rooms
  • Standard pathology (at Lancet/PathCare) requested by a specialist
  • Interventional procedures performed by radiologists
  • Acute medicine administered and dispensed by a specialist
  • Acute medicine prescribed by a specialist and obtained from a network pharmacy
100% of the MT
M = R2 650 per year
M += R3 710 per year
  • Authorised PMB chronic medicine prescribed by a specialist on referral by a Necesse network GP – subject to pre-authorisation and obtained from a network pharmacy
100% according to the Necesse PMB formulary
MEDICINE
  • Acute medicine
    • Dispensed by a dispensing Necesse network GP (included in the consultation fee)
100% of the MT
    • Formulary medicine obtained from a network pharmacy and prescribed by a Necesse network GP or Denis network dentist
100% of the MMAP according to the Necesse acute medicine/dental formularies
    • Over-the-counter (OTC) medicine obtained from a network pharmacy
100% of the MMAP
R90 per event
R250 per beneficiary per year
    • Authorised PMB chronic medicine obtained from a network pharmacy
      Subject to pre-authorisation, protocols and formulary
100% of the MHRP according to the Necesse PMB chronic medicine formulary
Unlimited
PHYSIOTHERAPY AND OCCUPATIONAL THERAPY
Out of hospital
Must be requested by a Necesse network GP
100% of the MT
M = R1 700 per year
M+ = R2 650 per year
OXYGEN
Out of hospital
Prescribed by a Necesse GP or specialist on referral and subject to pre-authorisation and clinical protocols
100% of the MT
STANDARD RADIOLOGY (X-RAYS)
Subject to Scheme-approved codes and referred by a Necesse network GP
  • Black and white X-rays and soft-tissue ultrasound scans only as per the Scheme’s clinical protocols
100% of the MT
PATHOLOGY
Subject to a list of pathology codes and tests only, done by Lancet/PathCare on request of a Necesse network GP
100% of the MT
OPTOMETRY
Benefits are subject to pre-authorisation by PPN
  • Optometric examinations
    1 composite consultation, including refraction test, tonometry and visual field test
100% of the MT
1 composite examination per beneficiary per 24-month cycle
  • Spectacles or contact lenses
    Benefits are limited to either spectacles or contact lenses:
    • Spectacles
      • Frames and/or lens enhancements
R200 per beneficiary per 24-month cycle

      • Lenses (one pair of standard clear Aquity lenses)
Single vision or bifocal or multifocal (paid at the cost of bifocal lenses) lenses per beneficiary per 24-month cycle
    • Contact lenses
R395 per beneficiary per 24-month cycle
DENTAL SERVICES
Subject to Denis managed care protocols and services rendered by a Denis network dentist
Conservative services
  • Routine check-ups
100% of the MT
1 per beneficiary per year
  • Fillings (X-rays and treatment plans may be requested for multiple fillings)
100% of the MT
4 fillings per beneficiary, 1 filling per tooth in 365 days Amalgam fillings (item codes 8341/8342/8343/8344) and resin restorations in anterior teeth (item codes 8351/8352/8353/8354)
  • Oral hygiene
    Only children younger than 16 years
    • 1 fluoride treatment per beneficiary per year for children from 5 - 16 years
    • Fissure sealants
100% of the MT
1 polish (item code 8155) or 1 scale and polish (item code 8159) treatment per year
  • Tooth extractions
100% of the MT
  • Root canal treatment in the dentist’s chair
100% of the MT
2 teeth per beneficiary per year
  • Plastic dentures, including associated laboratory costs
80% of the MT
1 set of plastic dentures (upper and lower jaw) per family (21 years and older) in a 2-year period
  • Laughing gas (in the dentist’s chair)
100% of the MT
  • Dental procedures under conscious sedation in the dentist’s chair (sedation cost), subject to pre-authorisation
100% of the MT
Extensive dental treatment only
  • X-rays
    • Intra-oral
100% of the MT
4 per beneficiary per year
    • Extra-oral
100% of the MT
1 per beneficiary in a 3-year period
Medicine
Only formulary medicine obtained from a network pharmacy and prescribed by a Denis network dentist
100% of the MMAP according to the acute medicine/dental formularies
GP - General practitioner
PPN - Preferred Provider Negotiators
MMAP - Maximum Medical Aid Price
MHRP - Medihelp Reference Price
OTC - Over the counter
M - Member
MT - Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price

Deductibles

 
Visiting the Necesse network service providers, following the correct pre-authorisation process, and using the Necesse formularies are just some of the ways in which you can manage or reduce out-of-pocket medical expenses.

PRE-AUTHORISATION, FORMULARIES AND REFERALS ARE IMPORTANT
100% of the Medihelp tariff will apply if the following services or procedures are pre-authorised and/or patients are referred by a Necesse network general practitioner, protocols are followed and DSPs are used:

Pre-authorisation
  • All planned hospital admissions in a Necesse network hospital (protocols and case management apply)
  • Oxygen for out-of-hospital use (protocols and case management apply)
  • Extensive dental treatment under general anaesthesia for children younger than 5 years – once per lifetime (Denis managed care protocols and PMB apply)
  • Dental procedures under conscious sedation in the dentist’s chair (extensive dental treatment only)
  • Midwife services, pre-and post-natal care
  • Referrals to gynaecologists by a Necesse network GP
  • Specialist care, subject to referral by a Necesse network GP
  • Oncology at ICON (PMB)
  • PMB chronic medicine
Should these services not be pre-authorised or the correct procedures not be followed, an 80% benefit will apply or you may be responsible for the account.

Emergency services
Emergency transport services (ER24) by road and air in the RSA must be pre-authorised to qualify for the applicable benefit. If not pre-authorised, a 50% benefit will apply, except in the case of emergency medical conditions.

Formularies (acute, dental and PMB medicine)
100% of the MT will apply when using the Necesse formularies. If you deviate from the Necesse formularies, you will be responsible for the payment.

Pathology and radiology lists
100% of the MT according to scheme-approved list of codes, as well as DSP (Lancet/PathCare) in the case of pathology. If you receive services not included on the lists or do not use Lancet or PathCare, you will be responsible for payment.

Referrals
100% of the MT will apply if you are referred to a specialist by your Necesse network GP. If you refer yourself an 80% benefit will apply.

USE OF NETWORK PROVIDERS
100% of the MT will apply when using the network providers. Should you choose not to use a network provider:
  • A 65% benefit will be applicable for non-network hospital visits, and
  • You will be liable for payment of other providers’ services.
DSP - Designated service provider
GP - General practitioner
ICON - Independent Clinical Oncology Network
PMB  - Prescribed minimum  benefits 
MT  - Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price
Important notes:
  • If a beneficiary joins during the course of a financial year, the medical aid benefits are calculated pro rata according to the remaining number of months per year.
  • 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. Phone Medihelp on 086 0100 678 if you have any enquiries about the Rules of Medihelp Medical Scheme.