Medihelp Elite Comprehensive medical aid plan: 2020

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Elite Comprehensive
Total Cost pm:

Main member:

R5,304

Adult:

R4,956

Child:

R1,440
Savings (per year):
  • No savings option on this plan
Extended Fund: RM = R2,750
M1 = R4,700
M2= R5,800
M3= R7,050
R R

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IN HOSPITAL PROCEDURES:
Elite Comprehensive
Scheme Benefits: Notes and Links:
non-Network Specialists:
  • 100% scheme rate
network Specialists:
  • 100% scheme rate
non-Network GPs:
  • 100% scheme rate
network GPs:
  • 100% scheme rate
Hospital Choice:
  • Choose any hospital
Penalty for using other hospital:
  • n/a
  • n/a
Specialised Radiology:
  • R1,100 co-payment
  • In and out of hospital
Supplementary Services: (Physio, etc)
  • Up to 100% scheme rate
  • Professional services for up to 30 days after discharge following hospital admission: speech therapy, occupational therapy and physiotherapy. R1,750 per person and R2,400 per family
  • The Blue Plan gap cover will increase this to 500% scheme rate
Transplants:
  • Cornea implants: R28,800 per implant
  • Otherwise, unlimited
Co-payments:
    (2019 benefit)
  • Back and neck fusion: R7,400 co-payment
  • In-hospital dentistry for children younger than 5yrs and removal of impacted teeth: R820 co-payment
  • Specialised radiology (MRIs and CT Scans): R1,100 co-payment
    Gastroscopy and Colonoscopy:
  • in doctor's rooms: no co-payment
  • in day hospital: R2,000 co-payment
  • in-hospital: R3,050 co-payment
  • Co-payments paid by you or your gap cover
Alternatives to hospitals:
  • Hospice and sub-acute facilities: paid by scheme, subject to authorisation
  • Private nursing: paid by scheme, subject to authorisation
Casualty:
  • From day-to-day benefits
  • Both the Blue Plan and Red Plan gap cover will pay up to R10,000 per person for unpaid casualty costs in event of emergency
Other:
  • Robotic assisted laparoscopic procedure for prostatectomy: R111,000 per person
  • Neurostimulators: R111,900 per person
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R165,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R165,000 limit)
  • Gap only supplements payment for procedures approved or authorised by your medical aid, and does not cover “penalties” (such as if, for example, you choose a non-DSP doctor for your procedure when the plan required a DSP doctor)

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All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme.
The gap benefits listed are for AskAdam gaps, unless otherwise stated. Actual benefits depend on gap choice option.

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OUT OF HOSPITAL BENEFITS (non-PMB):
Elite Comprehensive
Scheme Benefits Notes and Links:
Main Member: Adult: Child:
Savings /yr: No savings option on this plan
Extended Fund: RM = R2,750
M1 = R4,700
M2= R5,800
M3= R7,050
R R
General info:
  • Consider getting Primary Health Care (PHC) (medical insurance) that will cover you for all GP visits, some specialist visits, acute meds, minor out of hospital procedures, some radiology and pathology, dentistry, optometry and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
GP consultations:
  • Benefit shared with GPs, specialists, physiotherapy, psychologist, psychiatric nursing and supplementary services. Paid up to limits below
  • Main M1 M2 M3+
    R2,750 R4,700 R5,800 R7,050
  • See Primary Health Care benefit above
Childcare:
  • Children under a year receive 2 additional GP or specialist consults
Specialists consultations:
  • See GP benefit, above
  • See Primary Health Care benefit above
Pathology:
    R2,750 per family
  • See Primary Health Care benefit above
General radiology:
    R2,750 per family
  • See Primary Health Care benefit above
Specialised radiology:
  • R1,650 co-payment, in or out of hospital, unless PMB
Supplementary Services: (Physio, etc)
  • Benefit shared with GPs, specialists, physiotherapy, psychologist, psychiatric nursing and supplementary services. Paid up to limits below
  • Main M1 M2 M3+
    R2,750 R4,700 R5,800 R7,050
  • Also, speech therapy, occupational therapy and physiotherapy for up to 30 days after discharge following hospital admission. Limited to R1,750 per person and R2,400 per family

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MATERNITY BENEFITS:
Elite Comprehensive
Scheme Benefits Notes and Links:
Hospital stay:
  • Hospital delivery: 100% scheme rate
  • Home delivery: R13,000per event
  • The Blue Plan gap cover will increase this to 500% scheme rate
Consultations:
  • 12 consults, paid by scheme
Scans:
  • 2 x 2D scans, paid by scheme
  • One amniocentesis

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CANCER (ONCOLOGY):
Elite Comprehensive
Scheme Benefits Notes and Links:
Overall coverage (in and out of hospital):
  • R400,000 per family per year

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DENTISTRY:
Elite Comprehensive
Scheme Benefits Notes and Links:
Standard Dentistry:
  • Standard Dentistry: paid by scheme.
  • Includes:
    • 2 annual checkups
    • X-rays. (Extra-oral 1 every 3 years)
    • 2 annual scale and polish treatments per person
    • Fissure sealants for under 16yr olds
    • Fluoride treatments for children 5-13yrs
    • One filling per tooth per year
    • Extractions and root canals
    • Plastic dentures, 1 set per person every 4 years
Specialised Dentistry:
  • Partial metal frame dentures: 2 sets per person every 5 years
  • Crowns and bridges: 2 crowns per family per year
  • Implants: No benefit
In-Hospital Dentistry:
  • Maxilo-facial surgery: 100% scheme rate
Orthodontics:
  • R11,300 per person per lifetime, 9-18 yrs only. Paid by scheme.
Maxillo Facial Surgery:
  • 100% scheme rate, paid by scheme

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MEDICATION:
Elite Comprehensive
Scheme Benefits: Notes and Links:
Chronic:
  • Conditions covered:27 CDL conditions
  • Co-payment for use of non-formulary:
  • non-PMBs: up to limits below for generic medicines:
Main M1 M2 M3+
R4,500 R6,850 R9,150 R9,800
Acute (presrcibed) medication:
  • Benefit shared with medicine dispensed at emergency unit, OTC, vaccines, contraceptives, homeopathis and herbal, naturopathic and osteopathic medicine, up to the limits below
Main M1 M2 M3+
R4,250 R7,200 R8,850 R9,450
  • Consider getting Primary Health Care (medical insurance) that will cover you for all GP visits, some specialist visits, acute meds, minor out of hospital procedures, some radiology and pathology, dentistry, optometry and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
Over-the-counter:
  • Benefit shared with medicine dispensed at emergency unit, OTC, vaccines, contraceptives, homeopathis and herbal, naturopathic and osteopathic medicine, up to the limits below
Main M1 M2 M3+
R4,250 R7,200 R8,850 R9,450
Birth Control:
  • Benefit shared with medicine dispensed at emergency unit, OTC, vaccines, contraceptives, homeopathis and herbal, naturopathic and osteopathic medicine, up to the limits below
Main M1 M2 M3+
R4,250 R7,200 R8,850 R9,450
On Discharge:
  • R350 per admission
Biological:
  • No benefit, unless PMB level of care

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OPTOMETRY:
Elite Comprehensive
Scheme Benefits: Notes and Links:
Optometry:
Limit:Paid by scheme, every 2 years
Consult:1 per person
Frames:R1,000 per person
Single lenses1 set per person
Bifocals:
Multifocals
ContactsR1,635 per person
Refractive Surgery:
Notes:

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MENTAL HEALTH:
Elite Comprehensive
Scheme Benefits Notes and Links:
In-hospital:
  • R35,400 per person and R49,100 per family
Out-of-hospital:
  • Benefit shared with GPs, specialists, physiotherapy, psychologist, psychiatric nursing and supplementary services. Paid up to limits below
Main M1 M2 M3+
R2,750 R4,700 R5,800 R7,050
Trauma:
  • PMB conditions are covered for in and out of hospital treatment. For a full list see here.
  • Example of PMB condition: Acute stress disorder accompanied by recent significant trauma, including physical or sexual abuse. Treatment includes hospital admission for psychotherapy / counselling up to 3 days, or up to 12 outpatient psychotherapy / counselling contacts

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OTHER BENEFITS:
Elite Comprehensive
Scheme Benefits Notes and Links:
General Appliances:
  • Medical Appliances, hyperbaric oxygen: R1,500
  • Stoma products and urine bags: paid by scheme
  • CPAP apparatus: R9,700 per person every two years
1.1. Hearing Aids:
  • R7,900 per family every 3 years, paid by scheme
1.2. Wheelchairs:
  • R6,300 per family every 3 years, paid by scheme
Dialysis:
  • Unlimited
International Insurance:
  • Transport by road outside RSA: R2,050 per event
  • Transport by air outside RSA: R13,700 per event
Other:

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WELLNESS/PREVENTATIVE BENEFITS:
Elite Comprehensive
Scheme Benefits: Notes and Links:
Flu vaccination:
  • Covered
Pneumonia vaccines:
  • Covered, 55yrs+
Biometric Screening:
  • Covered
Child Immunisation:
  • Covered
Pap Smear:
  • Covered, every 3 years
Mammogram:
  • Covered, 40yrs+, every 2 years
PAS Test:
  • Covered, 40yrs+
HIV Test:
  • Covered
Other:
  • FOBT, 50yrs+
  • Bone density, women 50yrs+
  • Tetanus vaccine
  • HPV vaccine, 10-26 yrs

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PROSTHETICS:
Elite Comprehensive
Scheme Benefits: Notes and Links:
Overal Limit: Most non-PMB sublimits are increased by gap cover, if authorised by medical aid
  • EVARS prosthesis: R130,600
  • Vascular/cardiac prosthesis: R55,900
  • Health-essential functional prosthesis: R61,900. This includes non-PMB hip, knee and shoulder replacements
  • Wear and tear for hip and knee prosthesis: Subject to DSP if PMB, otherwise R19,600 for hospital and components
  • Intra-ocular lenses: R4,150 per lens, 2 lenses per beneficiary per year and subject to health-essential functional prosthesis benefit (above)
  • Prosthesis with reconstructive or restorative surgery, (in and out of hospital) or external breast prostheses, (in and out of hospital): R9,600 per family per year
  • Cochlear implants: R105,100 per person
  • Artificial eyes: R7,900 per person, every 3 years
  • Artificial limbs: R6,300 per person, every 3 years
Sub-limits:
  • Up to 100% scheme rate

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    Important!
  • Unless specified, assume that all benefits are paid are paid at 100% scheme rate
  • No limits or co-payments can apply to treatment of PMBs, which is always unlimited, although subject to strict protocols and scheme rules.
  • “Unlimited” benefits are still subject to authorisation, protocols and sublimits
  • Assume that all benefits need to be pre-authorised