The scheme might still cover some or all day-to-day claims. See below, and see benefits.
Extended Fund: Extra funds from the scheme for (mostly) out of hospital claims, over and above any savings account
Main= R1,450
Main+1= R2,800
Children Rates:
Child rates up to age 26.
Only pay for 2 children under 18yrs
Note:
Exclusions: Note that all schemes have extensive exclusions. We've tried to list the major ones, but you must consult with your scheme to get the full list.
All treatments and procedures are subject to authorisation and protocols
All benefits are listed as an indication only. Please verify with your broker and scheme
Assume scheme pays all these costs, unless otherwise stated
non-Network Specialists:
100% scheme rate
Scheme rate is set by Medihelp
network Specialists:
100% scheme rate
non-Network GPs:
100% scheme rate
network GPs:
100% scheme rate
Hospital Choice:
Long stay: Any hospital
Day procedure: Any Day hospital
Day Hospitals:
Procedures requiring Day hospital use: Ophthalmological, dental, endoscopic and
ear, nose and throat procedures, removal of
skin lesions, circumcisions and other case-by-case pre-authorised procedures
Penalty for using other hospital:
Use of non-Day hospital for certain procedures: 35% co-payment
You don't pay a penalty if admission was unavoidable due an emergency
Other Co-payments:
Spinal Column surgery: R16,500 co-payment
Endoscopic procedures, in day hospital (all scopes): R4,800 co-payment
Endoscopic procedures, in rooms (all scopes): no co-payment
Dental procedures: R3,880 co-payment
Specialized radiology: R3,000-R3,650 co-payment
Prostatectomy: R7,550 co-payment
Hysterectomy and Endometrial Ablation: R7,550 co-payment
* There might be other co-payments if you don't use scheme-chosen provider for some services.
* Treatment required for PMB level care is always paid by scheme, with no co-payment, if you follow the protocols. That means that these co-payments might not apply in your case! More info here
Specialised Radiology:
MRI and CT scan: R3,550 co-payment, in and out of hospital. (R3,000 co-payment if out of hospital)
Angiography: Unlimited, in and out of hospital
No limits or co-payments for PMB level care and/or for emergency
Supplementary Services: (Physio, etc)
100% scheme rate
No limits or co-payments for PMB level care and/or for emergency
Transplants:
PMBs only
Cornea implants: R34,200 per implant
Bone marrow/stem cell transplant: No benefit, unless PMB
Dialysis:
Scheme rate, in and out of hospital
Exclusions:
* Treatment required for PMB level of care is always paid by scheme, if you follow the protocols. It cannot be excluded. More info here.
* All schemes have extensive exclusions. We've tried to list the major ones here, but please consult your scheme or broker to get the full list
Alternatives to hospitals:
Hospice as an alternative to hospitalisation: Covered
Subacute care as an alternative to hospitalisation: Covered
Private Nursing as an alternative to hospitalisation: Covered
All medical aids must pay for the diagnosis, treatment and management of all PMB conditions, in or out of hospital. You can see a full list of the conditions here.
This can include consults with specialists, blood or other tests, radiology and medicine
The benefit is paid by the scheme, and not out of your savings account
If you have no day-to-day funds, you still have cover for PMBs
Schemes usually impose the use of specific providers for treatment of PMBs. Read more about that here.
Care extender benefit: One GP consult for family once you complete any one Pap smear, mammogram, prostate test, faecal occult blood test (FOBT) or bone mineral density test
Otherwise, from day-to-day benefit
Treatment required for PMB conditions is always paid paid by scheme, with no co-payment, if you follow the protocols. More info here
Childcare:
Conservative dentistry, for under 18yrs
Paediatrician/GP/ENT: 2 consults, 0-2yrs
Immunisations: Covered, up to 7yrs
Flu shot: Covered
Specialists consultations:
From day-to-day benefit
Treatment required for PMB conditions is always paid paid by scheme, with no co-payment, if you follow the protocols. More info here
Pathology:
PMBs only
General radiology:
PMBs only
Specialised radiology:
MRI and CT scan: R3,550 co-payment, in and out of hospital. (R3,000 co-payment if out of hospital)
Angiography: Unlimited, in and out of hospital
Scans required for PMB level care are paid paid by scheme, with no co-payment, if you follow the protocols. More info here
Supplementary Services: (Physio, etc)
Occupational and speech therapy, dietician services, audiometry, podiatry, massage, orthoptic, chiropractic, homeopathic, herbal and naturopathic, osteopathic, and biokinetic services: No benefit
General Appliances:
No benefit
1.1. Hearing Aids:
No benefit
1.2. Wheelchairs:
No benefit
Note:
PMBs: Prescribed Minimum Benefits. To read more about PMBs click here
DSPs: Designated Service Provders. Where stipulated, you must use specific specific providers to get full benefit.
Co-payment: Paid out of pocket, or out of savings account. Sometimes this is refundable to you if you have a gap product
All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme. The benefits listed here are an indication only. Please verify all benefits and their conditions with the scheme.
You might be required to use specific pharmacies and be limited to specific medicines
Acute (presrcibed) medication:
From day-to-day benefit
Over-the-counter:
Care extender benefit: R490 for over the counter meds once you complete a health screening
Birth Control:
Oral, injectable: R150 per month up to R2,000 per year
IUD: R2,250 every 60 months
On Discharge:
R400 per admission
Biological:
PMBs only
Treatment that is required (by law) for PMB conditions is always paid paid by scheme, with no co-payment, if you follow the protocols. More info here.)
Note:
Schemes have very strict rules about where you can get your medicine to get full benefit. We do not list the requirements here, so confirm with your scheme before you collect your medicine.
Formulary: A pre-defined list of approved medicines. Each plan has a different list, and might not pay for non-listed medicine. Confirm with your scheme whether your required medicine is covered by them.
PMBs: Prescribed Minimum Benfits. To read more about PMBs click here
DSPs: Designated Service Provders. Where stipulated, you must use specific specific providers to get full benefit.
Co-payment: Paid out of pocket, or out of savings account. Sometimes this is refundable to you if you have a gap product
All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme. The benefits listed here are an indication only. Please verify all benefits and their conditions with the scheme.
A quick guide to how you can change your medical aid plan, including the resignation procedure, and things to look out for, such as imposed waiting periods from your new scheme
