Medihelp Necesse Student A medical aid plan: 2020

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Necesse A
2020 Costs:
Total Cost pm:

Main member:

R597

Adult:

R597

Child:

R597
Savings (per year):
  • No savings option on this plan
Income band:



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IN HOSPITAL PROCEDURES:
Necesse A
Scheme Benefits: Notes and Links:
non-Network Specialists:
  • The Blue Plan gap cover will increase this to 500% scheme rate
network Specialists:
  • 100% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
non-Network GPs:
  • 100% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
network GPs:
  • 100% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
Hospital Choice:
  • Choose a Network Hospital
Penalty for using other hospital:
Specialised Radiology:
  • R16,500 per family
  • In and out of hospital
Supplementary Services: (Physio, etc)
  • Physiotherapy and occupational therapy: R9,850 per family
  • The Blue Plan gap cover will increase this to 500% scheme rate
Transplants:
  • PMBs only
  • Cornea implants: R28,800 per implant
Co-payments:
  • N/A
Alternatives to hospitals:
  • Private nursing and sub-acute care: R22,300 per family, subject to authorisation.
Casualty:
  • Unlimited for PMBs, otherwise 80% of scheme rate up to R1,100 per person and R2,250 per family
  • Radiology 65% scheme rate and forms part of above limit
  • Pathology 100% rate, separate from above limit
  • Excludes facility fee
  • Both the Blue Plan and Red Plan gap cover will pay up to R20,000 per person for unpaid casualty costs in event of emergency
Other:
  • Pathology, standard radiology and clinical technologist services: R30,500 per family
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R157,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R157,000 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):
Necesse A
Scheme Benefits Notes and Links:
Main Member: Adult: Child:
Savings /yr: No savings option on this plan
General info:
  • Our recommended gap cover does not pay out-of-hospital claims, unless it is for cancer treatment, dialysis, or MRI/CT scans
GP consultations:
  • Network GP: 9 consults per person
  • . Thereafter PMBs only.
Childcare:
Specialists consultations:
  • Specialist care (consult and treatment or intervention): M =R2,950 and M+ =R3,050
  • This benefit covers specialist consultations, surgical and non-surgical procedures, endoscopic procedures, radiology interventions, pathology, acute medicine
Pathology:
  • Paid by scheme
General radiology:
  • Paid by scheme
Specialised radiology:
  • R16,500 per family, in and out of hospital
  • Sublimit increased as necessary for MRI and CT scans
Supplementary Services: (Physio, etc)
    Physiotherapy and Occupational therapy: M= R1,950 and M+ =R3,200



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MATERNITY BENEFITS:
Necesse A
Scheme Benefits Notes and Links:
Hospital stay:
  • Hospital delivery: 100% scheme rate
  • Elective C-section: R26,300
  • Home delivery: R13,000
  • The Blue Plan gap cover will increase this to 500% scheme rate
Consultations:
  • GP: 9 consults, shared with GP benefit.
  • 2 consults with gynaecologist
  • Midwife service, pre and post natalcare: Unlimited
Scans:
  • 2 x 2D scans, paid by scheme



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CANCER (ONCOLOGY):
Necesse A
Scheme Benefits Notes and Links:
Overall coverage (in and out of hospital):
  • PMBs only



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DENTISTRY:
Necesse A
Scheme Benefits Notes and Links:
Standard Dentistry:
  • Standard Dentistry: paid by scheme.
  • Includes:
    • 1 annual checkup
    • X-rays, 4 per person per year. (Extra-oral 1 every 3 years)
    • 1 annual scale or polish treatments per person
    • 4 fillings per person per year
    • Extractions and root canals
    • Fluoride treatment (5-13yrs) and Fissure sealants (under 16yrs)
    • Plastic dentures, 1 set per family every 2 years
Specialised Dentistry:
  • Plastic dentures: 1 set per family every 2 years
In-Hospital Dentistry:
  • Maxilo-facial surgery: No benefit, unless PMB
  • In-hospital: PMBs only for children under 5yrs
  • Orthodontics:
    • No benefit
    Maxillo Facial Surgery:
    • PMBs only



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    MEDICATION:
    Necesse A
    Scheme Benefits: Notes and Links:
    Chronic:
    • All medical aid plans pay for treatment of the 27 CDL conditions as required by law. This includes medicine as well as GP or specialist consults, tests etc. Find out more
    • If you voluntarily use medicine that is not on Medihelp's list ("formulary"), you pay a 40% co-payment
    Acute (presrcibed) medication:
    • If dispensed by GP: 100% of scheme rate
    • If dispensed by pharmacy: 100% of MMAP (maximum medical aid price)
    • 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:
    • R100 per event, R290 per person per year
    Birth Control:
    On Discharge:
    • R340 per admission
    Biological:
    • No benefit, unless PMB level of care



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    OPTOMETRY:
    Necesse A
    Scheme Benefits: Notes and Links:
    Optometry:
    Limit:Paid by scheme, every 2 years
    Consult:1 per person
    Frames:R550 per person
    Single lenses1 set per person
    Bifocals:
    Multifocals
    ContactsR730 per person
    Refractive Surgery:
    Notes:From network provider



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    MENTAL HEALTH:
    Necesse A
    Scheme Benefits Notes and Links:
    In-hospital:
    Out-of-hospital:
    • PMBs only
    Trauma:
    • Netcare 911 phoneline



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    OTHER BENEFITS:
    Necesse A
    Scheme Benefits Notes and Links:
    General Appliances:
    • PMB cases: back, leg, arm and neck supports, crutches, orthopaedic footwear, elastic stockings, peakflow meters, nebulisers: 100% scheem rate
    • CPAP: R9,700 per person every 24 months
    1.1. Hearing Aids:
    • No benefit, unless PMB
    1.2. Wheelchairs:
    • R4,700 per family, every 3 years
    Dialysis:
    • PMBs only
    International Insurance:
    Other:



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    WELLNESS/PREVENTATIVE BENEFITS:
    Necesse A
    Scheme Benefits: Notes and Links:
    Flu vaccination:
    • Covered, from over-the-counter medicine benefit
    Pneumonia vaccines:
    • No benefit, unless PMB
    Biometric Screening:
    • Covered
    Child Immunisation:
    • No benefit, unless PMB
    Pap Smear:
    • Covered, every 3 years
    Mammogram:
    • Covered, 40yrs+, every 2 years
    PAS Test:
    • Covered, 40yrs+
    HIV Test:
    • Covered
    Other:
    • Bone density, women 50yrs+
    • Tetanus vaccine



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    PROSTHETICS:
    Necesse A
    Scheme Benefits: Notes and Links:
    Overal Limit:
    • Evars prosthesis, vascular/cardiac prosthesis, health-essential prosthesis: R23,000 per person
    • PMBs only
    Sub-limits:



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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