Necesse 2017

Necesse - 2017

from R438 per month

 

Necesse is an income-based network option that provides access to a network of quality providers, both for hospitalisation and day-to-day medical expenses. It’s the ideal option for full-time tertiary students and corporate clients.

Monthly contribution

Subscription
*Gross monthly incomePrincipal memberDependantChild dependant <21 years
R0 - R400
(Full-time student)
R438R438R438
R401 - R5 000R1 404R1 110R600
R5 001 - R7 000R1 464R1 170R660
R7 001 - R11 000R1 656R1 290R726
R11 001 and moreR1 932R1 506R834

* 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.

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: 3605/ 39175/ 34100/ 34101)
  • 1 prostate test (PSA level) > 40 years (pathology: 4519)
  • 1 bone mineral density test for women > 50 years (radiology imaging: 3604/ 50120)
  • 1 HIV test (pathology: 3932/ 4614)

IMMUNISATION (One immunisation per beneficiary per year requested by a Necesse network general practitioner)
  • 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 supports you with relevant health information through every life stage.  You can also: 

  • View, update and share your health information and results of your health assessment via the site
  • Add your activity tracker and view your performance
  • Join Medihelp MultiSport, receive sports gear at a discounted price and participate as part of the Medihelp team in supported events
  • Join lifestage-specific programmes such as the pregnancy and baby programme and receive added value.

Medihelp's 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 prostheses
    • EVARS prostheses
    • Vascular/cardiac prostheses
    • Health-essential functional prostheses
      • Intra-ocular lenses
    • Prosthesis with reconstructive or restorative surgery

100% of the cost

  • External breast prostheses (in and out of hospital) (PMB and non-PMB)
100% of the cost
R8 550 per family per year
MEDICAL, SURGICAL AND ORTHOPAEDIC APPLIANCES
Services in hospital and prescribed by a medical doctor
  • CPAP apparatus
100% of the cost
R8 400 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

R24 750 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

EMSEMERGENCY TRANSPORT SERVICES
Provided and pre-authorised by Netcare 911
Transport by road or air within the borders of South Africa
Subject to pre-authorisation and protocols

100% of the MT

Unlimited

24-HOUR HELPLINE AND TRAUMA COUNSELLING (Netcare 911)Phone 082 911
EMERGENCY UNITS AND NON-NETWORK CONSULTATIONS
  • PMB-related emergencies
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= R950 per year
M+= R1 950 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
R320 per admission
PHYSIOTHERAPY AND OCCUPATIONAL THERAPY
In hospital
100% of the MT
R8 500 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
R26 300 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
R14 200 per family per year
OXYGEN
In hospital
100% of the MT
CLINICAL TECHNOLOGIST SERVICES
In hospital
100% of the MT
R19 200 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
R22 700 per confinement for an elective caesarean section
PMB cases
Services rendered by a specialist on the Necesse specialist network, on referral by a Necesse 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
R11 350 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
R19 200 per family per year

APPENDECTOMY
Subject to pre-authorisation

  • Conventional procedure

100% of the MT

Unlimited

  • Laparoscopic procedure

100% of the MT

Hospitalisation:

R15 000 per beneficiary

PROSTATECTOMY
Subject to pre-authorisation

  • Conventional or laparoscopic procedure

100% of the MT

Unlimited

  • Robotic assisted laparoscopic procedure

100% of the MT

Hospitalisation:

R95 000 per beneficiary

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: 98% 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 ICON or that deviates from the protocols is subject to deductibles.

Day-to-day benefits

DescriptionBenefit
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 800 per year
M += R3 900 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
    • Self-medication obtained from a network pharmacy
100% of the MMAP
R100 per event
R260 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 800 per year
M+ = R2 800 per year
OXYGEN
Out of hospital
Prescribed by a medical doctor 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 medical doctor 
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 (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 dental formulary
GP-General practitioner
PPN-Preferred Provider Negotiators
MMAP-Maximum Medical Aid Price
MHRP-Medihelp Reference Price
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 REFERRALS 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 (Netcare 911) 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 Medihelp-approved list of codes, as well as for services rendered by the 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 or a co-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 HOSPITALS
100% of the MT will apply when using the network hospitals. Should you choose not to use a network hospital a 65% benefit will be applicable for non-network hospital visits.
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.

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