Terms
Added insured benefits
Benefits provided on top of your day-to-day cover. These include preventive health screenings, immunisations, and pregnancy and baby benefits.
Back and Neck Treatment Programme
A non-surgical programme for back and neck pain, run by DBC (Documentation Based Care). Treatment is tailored to each patient's diagnosis. Patients must be assessed before joining and must complete the programme before spinal surgery will be approved. This programme is not available to MedMove! members.
Benefit cycle
The period a benefit covers, starting from the date you first use it. Each new cycle begins after the previous one ends, regardless of any break in membership, plan changes, or re-registration.
Cancer benefits
Most cancer cases qualify as prescribed minimum benefits (PMBs), which Medihelp covers in full according to prescribed treatment guidelines. Non-PMB cancer is covered up to set amounts per plan, but only when treated by oncologists within the Icon network. All cancer treatment is assessed individually against Icon's protocols. Treatment outside Icon, or that does not follow Icon's protocols, will result in co-payments.
Care extender benefit
An incentive benefit you unlock by completing certain health screenings.
CDL (Chronic Disease List)
A list of 26 chronic conditions that must be covered under prescribed minimum benefits (PMBs) in terms of the Medical Schemes Act.
Co-payments
The portion of a medical bill you pay yourself, directly to the service provider. Co-payments apply when:
- Your doctor or provider charges more than Medihelp's tariff
- Your benefit covers less than 100% of the cost (for example, for original acute medicine), or the cost exceeds your benefit limit
- You use a provider outside the designated network (for example, a non-Icon oncologist for cancer treatment)
- A co-payment is specified for a particular procedure or benefit in the Scheme Rules
Contraceptives
Injectable, implantable, intra-uterine, and oral contraceptives.
Core benefits
Benefits that cover essential healthcare, such as hospitalisation. These are generally insured benefits and are included on all plans, though some may have co-payments, treatment guidelines, network restrictions, or limits.
Cost (PMB)
For PMB services, 'cost' means Medihelp pays the full amount, provided the service qualifies as a PMB, is registered with Medihelp, and is delivered by a designated service provider (DSP) following PMB treatment guidelines.
CPAP
A device that delivers continuous positive airway pressure to help with breathing.
Day procedure network
The Medihelp network of facilities where patients have procedures that do not require an overnight stay. MedMove! members must use this network for all day procedures or pay a 35% co-payment. All members are encouraged to use the network. All day procedures must be pre-authorised – failing to do so results in a 20% co-payment. Certain procedures, such as scopes, require an upfront payment that varies by plan.
Day-to-day benefits
Benefits that cover general, everyday medical expenses. Depending on your plan, these may be funded through a savings account, insured cover, or a combination of both.
DSP (designated service provider)
A provider that Medihelp has contracted or appointed to deliver specific medical services.
EVARS (endovascular aortic replacement surgery)
A surgical procedure covered subject to specific clinical criteria being met.
Formulary
A list of preferred medicines – selected for safety, effectiveness, and cost – used to treat specific conditions. The formulary applies to MedMove!, MedVital Elect, MedAdd Elect, and MedPrime Elect plans.
Hospital benefits
Benefits for services during a hospital stay, including ward accommodation, ward medicine, radiology, pathology, and in-hospital consultations. All planned admissions must be pre-authorised – failing to do so results in a 20% co-payment. Emergency admissions must be registered on the first workday after admission. Certain procedures performed in hospital, such as scopes and specialised radiology, require an upfront payment that varies by plan. Members on network plans who choose a non-network hospital must pay a 35% co-payment on the hospital account.
MHRP (Medihelp Reference Price)
The price Medihelp uses for pre-authorised PMB medicine, based on the most cost-effective evidence-based treatment. The MHRP varies by plan and may change as new generics enter the market. Check the latest prices on medihelp.co.za. Using medicine on the MHRP where possible will help you avoid or reduce co-payments.
MMAP (Maximum Medical Aid Price)
The reference price Medihelp uses to calculate benefits for acute and chronic medicine. It is based on the average price of all available generic equivalents for a patented medicine.
MT (Medihelp tariff)
The rate Medihelp pays for medical services. This includes contracted rates with hospital groups, the Medihelp Dental Tariff, and the single exit price for acute medicine. Tariffs are set out in the Rules of Medihelp.
Network plans
Plans where benefits are linked to a specific network of providers. Members on these plans must use network providers to qualify for full benefits and avoid co-payments. Use the provider search function on medihelp.co.za to find network providers for your plan.
Period
The specific timeframe that applies to a particular benefit – for example, the benefit year for dentistry – or the date you joined as a beneficiary.
PMBs (prescribed minimum benefits)
A set of benefits that all medical schemes must provide by law. PMBs cover 26 chronic conditions on the CDL, 271 diagnoses with their associated treatments, and emergency medical conditions. Medihelp must cover these in full, with no benefit limits. PMBs are subject to pre-authorisation, treatment protocols, and, where required, the use of designated service providers. PMB benefits are funded first from the relevant day-to-day benefits.
Primary care drug therapist
A pharmacist qualified to diagnose certain primary health conditions and prescribe medication for contraception and conditions such as diarrhoea, acne, insect and spider bites, and ear infections, among others.
Protocol
A set of clinical guidelines that sets out the best sequence of tests and treatments for a specific condition. This includes clinical practice guidelines, standard treatment guidelines, disease management guidelines, treatment algorithms, clinical pathways, and formularies.
Savings account
An account held by Medihelp as part of the Scheme's funds (available on plans that include a savings account). It is used to pay qualifying medical expenses. Unused funds carry over from year to year. A credit facility equal to the remaining months' savings contributions for the year is available upfront and unused funds carry over to the next year.
Self-medication
Over-the-counter medicine that does not require a prescription. Claims for self-medication must include valid NAPPI codes to be processed.
Telemedicine
Healthcare consultations conducted remotely using technology such as computers, phones, video calls, or messaging.
TTO (to take out)
Medicine dispensed by the hospital when you are discharged. A per-admission limit applies.
Vascular/cardiac prostheses
Devices used to replace or support damaged blood vessels or heart structures. These include artificial heart valves, vascular grafts, and implantable cardiac devices.
Virtual consultations
Consultations at Clicks, Dis-Chem, or other participating pharmacies, where registered nurses – supported by a network of accredited GPs – can diagnose conditions, prescribe medicine, and issue referrals where necessary.