Medihelp Dimension Prime 1 Network medical aid plan: 2019

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Please note that these benefits are still being updated as more information is made available to us. Always consult with your broker before making final decisions regarding your healthcare cover.

Prime 1 Network
2018 Costs:
Total Cost pm:

Main member:

R1,356

Adult:

R1,104

Child: Pay for max 2 children under 18yrs; all children 18-26yrs

R408
Savings Account:
  • No savings option on this plan
Extended Fund: RM = R1,100
M1 = R2,200
R R
2019 Costs:
Total Cost pm:

Main member:

R1,488
(9.73%)

Adult:

R1,212

Child: Pay for max 2 children under 18yrs; all children 18-26yrs

R450
Savings (per year):
  • No savings option on this plan
Extended Fund: RM = R1,100
M1 = R2,200
R R
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In brief (2018):
  • Scheme rate is 100%, and most day-to-day expenses are from small fund or from out-of-pocket.
  • Network hospitals
  • Specialised radiology in and out of hospital paid by scheme, with a co-payment
  • Medihelp does pay for most maternity expenses and preventative benefits such as mammograms and pap smears
  • You get R200,000, for non-PMB cancer cover
  • Wheelchair and hearing aid benefit
  • Diagnosis and treatment of the 270 PMBs is always paid by scheme, in and out of hospital, according to protocols.
See full benefits below

IN HOSPITAL PROCEDURES:
Prime 1 Network
Scheme Benefits: Gap Benefits:
Specialists:
  • Up to 100% scheme rate
  • You or gap cover pay the balance, if any
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
  • Recommended for this plan: Plan Blue, R295pm per family where no member is older than 64yrs (otherwise, R435pm per family)
Hospital Choice:
  • Choose a Network Hospital, or 35% co-payment if you voluntarily choose another hospital
  • No benefit, unless PMB
Specialised Radiology:
  • You or your gap pay R1,550 co-payment
  • In and out of hospital
  • Gap cover pays co-payments for procedures approved by medical aid
  • Out of hospital, co-payment paid for MRIs and CT scans only
  • 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
    • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals, for non-PMB treatment
    • No benefit for out-of-hospital services
    Transplants:
    • Cornea implants: R27,400 per implant
    • Otherwise, unlimited
    • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
    • Sublimits increased as necessary
    Co-payments:
    • Back and neck fusion: R11,000 co-payment
    • In-hospital dentistry for children younger than 5yrs and removal of impacted teeth: R3,000 co-payment, with dentist's account paid out of pocket
    • Gastroscopy and Colonoscopy:
      • in doctor's rooms: no co-payment
      • in day hospital: R2,000 co-payment
      • in-hospital: R3,050 co-payment
    • Specialised radiology (MRIs and CT Scans): R1,600 co-payment
    • Co-payments paid by you or your gap cover
    • Gap cover pays co-payments for procedures approved by medical aid
    Alternatives to hospitals:
    • Hospice and sub-acute facilities: paid by scheme, subject to authorisation
    • Private nursing: paid by scheme, subject to authorisation
    • No benefit, unless PMB
    Casualty:
    • No benefit, unless PMB
    • Pays up to R20,000 per person per year for emergency medical treatment not paid for by medical aid
    Other:
    • Robotic assisted laparoscopic procedure for prostatectomy: R105,400 per person
    • Neurostimulators: R106,200 per person
    • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
    • Sublimits increased as necessary
    Note:
    • Gap cover is an add-on to your medical aid, not a stand alone product
    • Gap cover has a maximum benefit payout of R150,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R150,000 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):
    Prime 1 Network
    Scheme Benefits Gap benefits
    Main: Adult: Child:
    Savings /yr: No savings option on this plan
    Extended Fund: RM = R1,100
    M1 = R2,200
    R R
    General info: 2019 Benefits coming November 9, 2018
    • Our recommended gap cover does not pay out-of-hospital claims, unless it is for cancer treatment, dialysis, or MRI/CT scans
    GP consultations:
    • R1,150 per person and R2,300 per family. Thereafter only PMBs.
    • Shared with GPs, specialists, physio, acute meds, otc meds, contraceptives, vacciness, herbal and homeopathic meds
    • No benefit, unless PMB
    Childcare:
    • Children under a year receive 2 additional GP or specialist consults
    • No extra benefit available
    Specialists consultations:
    • See GP benefit, above
    • No benefit, unless PMB
    Pathology:
    • No benefit, unless PMB
    • No benefit, unless PMB
    General radiology:
    • No benefit, unless PMB
    • No benefit, unless PMB
    Specialised radiology:
    • R1,600 co-payment, in or out of hospital, unless PMB
    • Co-payment paid, for authorised out of hospital MRI and CT Scans
    Supplementary Services: (Physio, etc)
    • Physiotherapy: shared with GP consult benefit
    • 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
    • No benefit, unless PMB
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    MATERNITY BENEFITS:
    Prime 1 Network
    Scheme Benefits Gap benefits
    Hospital stay:
    • Hospital delivery: 100% scheme rate
    • Home delivery: R12,400 per event
    • Pays up to 500% scheme rate for specialists, GPs and other medical professionals, in-hospital only
    Consultations:
    • 12 consults, paid by scheme
    • No benefit, unless PMB
    Scans:
    • 2 x 2D scans, paid by scheme
    • One amniocentesis
    2019 Benefits coming November 9, 2018
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    CANCER (ONCOLOGY):
    Prime 1 Network
    Scheme Benefits Gap benefits
    Overall coverage (in and out of hospital):
    • R200,000 per family per year for non-PMB cases
    • PMBs covered in full
    • Once you or the medical scheme have spent R200,000 per oncology treatment cycle from a private hospital, your sublimits increase as necessary. More info
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    DENTISTRY:
    Prime 1 Network
    Scheme Benefits Gap benefits
    Standard Dentistry:
    • No benefit
    Specialised Dentistry:
    • No benefit
    • Pays shortfalls and co-payments for in-hospital dentistry treatment approved by scheme
    In-Hospital Dentistry:
    • Maxilo-facial surgery: No benefit, unless PMB
    Orthodontics:
    • No benefit
    Maxillo Facial Surgery:
    • No benefit, unless PMB
    • Pays shortfalls and co-payments for any non-PMB in-hospital dentistry treatment approved by scheme. (PMB are paid in full by scheme if you use DSP)
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    MEDICATION:
    Prime 1 Network
    Scheme Benefits Gap benefits
    Chronic:
    • Conditions covered:27 CDL conditions
    • Co-payment for use of non-formulary:
    • No benefit, unless PMB
    Acute (presrcibed) medication:
    • R1,150 per person and R2,300 per family
    • Shared with GPs, specialists, physio, acute meds, otc meds, contraceptives, vacciness, herbal and homeopathic meds
    • No benefit, unless PMB
    Over-the-counter:
    • R1,150 per person and R2,300 per family
    • Shared with GPs, specialists, physio, acute meds, otc meds, contraceptives, vacciness, herbal and homeopathic meds
    • No benefit, unless PMB
    Birth Control:
    • R1,150 per person and R2,300 per family
    • Shared with GPs, specialists, physio, acute meds, otc meds, contraceptives, vacciness, herbal and homeopathic meds
    • No benefit, unless PMB
    On Discharge:
    • R340 per admission
    • No benefit, unless PMB
    Biological:
    • No benefit, unless PMB level of care
    • No benefit, unless PMB
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    OPTOMETRY:
    Prime 1 Network
    Scheme Benefits Gap benefits
    Optometry:
    Limit:No benefit
    Consult:n/a
    Frames:n/a
    Single lensesn/a
    Bifocals:n/a
    Multifocalsn/a
    Contactsn/a
    Refractive Surgery:n/a
    Notes:n/a
    • Pays shortfalls and co-payments for any non-PMB in-hospital treatment approved by scheme. (PMBs are paid in full by scheme if you use DSP)
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    MENTAL HEALTH:
    Prime 1 Network
    Scheme Benefits Gap benefits
    In-hospital: 2019 Benefits coming November 9, 2018
    • No benefit, unless PMB
    Out-of-hospital:
    • Psychiatry: See above
    • Psychology: No benefit
    • No benefit, unless PMB
    Trauma:
    • Netcare 911 phoneline
    • No benefit, unless PMB
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    OTHER BENEFITS:
    Prime 1 Network
    Scheme Benefits Gap benefits
    General Appliances:
    • Medical Appliances, hyperbaric oxygen: No benefit
    • Stoma products and urine bags: paid by scheme
    • CPAP apparatus: R9,250 per person every two years
    • No benefit
    1.1. Hearing Aids:
    • R4,500 per family every 3 years, paid by scheme
    • No benefit
    1.2. Wheelchairs:
    • R4,500 per family every 3 years, paid by scheme
    • No benefit
    Dialysis:
    • Unlimited
    2019 Benefits coming November 9, 2018
    HIV:
    • Post exposure prophylaxis in the event of sexual assault or accidental exposure to HIV
    • Paid by scheme
    • Since HIV is a PMB certain out-of-hospital benefits are automatically covered by all schemes according to protocols
    • No benefit
    Emergency Transport:
    • Netcare 911
    • No benefit
    International Insurance:
    • Transport by road outside RSA: R1,950 per event
    • Transport by air outside RSA: R13,000 per event
    • No benefit
    Other:
    • Oxygen out-of-hospital: paid by scheme
    • No benefit, unless PMB
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    WELLNESS/PREVENTATIVE BENEFITS:
    Prime 1 Network
    Scheme Benefits Gap benefits
    Flu vaccination:
    • Covered
    • No benefit
    Pneumonia vaccines:
    • Covered, 55yrs+
    • No benefit
    Back Rehabilitation Programme:
    • Covered
    • No benefit
    Biometric Screening:
    • Covered
    • No benefit
    Child Immunisation:
    • Covered
    • No benefit
    Pap Smear:
    • Covered
    • No benefit
    Mammogram:
    • Covered, 40yrs+
    • No benefit
    PAS Test:
    • Covered, 40yrs+
    • No benefit
    HIV Test:
    • Covered
    • No benefit
    Other:
    • FOBT, 50yrs+
    • Bone density, 50yrs+
    • Tetanus vaccine
    • HPV vaccine, 10-26 yrs
    • No benefit
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    PROSTHETICS:
    Prime 1 Network
    Scheme Benefits Gap benefits
    Overal Limit: Most non-PMB sublimits are increased by gap cover, if authorised by medical aid
    • EVARS prosthesis: R32,900
    • Vascular/cardiac prosthesis: R32,900
    • Health-essential functional prosthesis: R21,900. This includes non-PMB hip, knee and shoulder replacements, with no benefit for wear and tear
    • Intra-ocular lenses: R3,950 per lens, 2 lenses per beneficiary per year and subject to health-essential functional prosthesis benefit (above)
    • Prosthesis with reconstructive or restorative surgery and/or external breast prostheses (in and out of hospital): R4,050 per family per year
    • Cochlear implants: No benefit
    • Artificial eyes: R4,500 per family, every 3 years
    • Artificial limbs: R4,500 per family, every 3 years
    • Sublimit increased by up to R150,000 per person
    • No benefit for procedures excluded by medical aid
    Sub-limits:
    • Up to 100% scheme rate
    • Sublimit increased by up to R150,000 per person
    • No benefit for procedures excluded by medical aid
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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