Medihelp Dimension Prime 2 Network medical aid plan: 2018

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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.

Dimension Prime 2 Network
2018 Costs:
Total Cost pm:

Main member:

R1,800

Adult:

R1,476

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

R534
Savings Account (yr): R3,240 R2,664 R936
2019 Costs:
Total Cost pm:

Main member:

R
(%)

Adult:

R

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

R
In brief (2018):
  • Scheme rate is 100%, and most day-to-day expenses are from savings 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 R100,000, for non-PMB cancer cover
  • 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:
Dimension Prime 2 Network
Scheme Benefits: Gap Benefits:
Specialists:
  • 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:
  • Network hospitals
  • No benefit
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)
    • 100% scheme rate
    • Professional services for up to 30 days after discharge following hospital admission: speech therapy, occupational therapy and physiotherapy. R1,700 per person and R2,300 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: R26,100 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: R9,500 co-payment
    • In-hospital dentistry for children younger than 5yrs and removal of impacted teeth: R2,900 co-payment, with dentist's account paid out of pocket or from savings
    • Gastroscopy and Colonoscopy:
      • in doctor's rooms: no co-payment
      • in day hospital: R2,550 co-payment
      • in-hospital: R3,550 co-payment
    • Specialised radiology (MRIs and CT Scans): R1,550 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
    Casualty:
    • Paid from day-to-day benefit
    • Pays up to R20,000 per person per year for emergency medical treatment not paid for by medical aid
    Other:
    • Laparoscopic appendectomy: R15,800 per person
    • Robotic assisted laparoscopic procedure for prostatectomy: R100,400 per person
    • Neurostimulators: R101,200 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)

    No phone calls!
    Our quote will include the right gap cover for this plan

    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):
    Dimension Prime 2 Network
    Scheme Benefits Gap benefits
    Main: Adult: Child:
    Savings /yr: R3,240 R2,664 R936
    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:
      Paid from day-to-day benefit , unless PMB.
    • No benefit
    Childcare:
    • No extra benefit available
    Specialists consultations:
      Paid from day-to-day benefit benefit.
    • No benefit
    Pathology:
    • Paid from day-to-day benefit
    • No benefit
    General radiology:
    • Paid from day-to-day benefit
    • No benefit
    Specialised radiology:
    • R1,550 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 R1,700 per person and R2,300 per family
    • No benefit

    No phone calls!
    Our quote will include the right gap cover for this plan

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    MATERNITY BENEFITS:
    Dimension Prime 2 Network
    Scheme Benefits Gap benefits
    Hospital stay:
    • Hospital delivery: 100% scheme rate
    • Home delivery: R11,900
    • Pays up to 500% scheme rate for specialists, GPs and other medical professionals, in-hospital only
    Consultations:
    • 8 consults, paid by scheme
    • 2 paediatric consults, paid by scheme
    • No benefit
    Scans:
    • 2 x 2D scans, paid by scheme
    • No benefit

    No phone calls!
    Our quote will include the right gap cover for this plan

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    CANCER (ONCOLOGY):
    Dimension Prime 2 Network
    Scheme Benefits Gap benefits
    Overall coverage (in and out of hospital):
    • R100,000 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

    No phone calls!
    Our quote will include the right gap cover for this plan

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    DENTISTRY:
    Dimension Prime 2 Network
    Scheme Benefits Gap benefits
    Dentistry:
    • From day-to-day benefit
    • Removal of impacted wisdom teeth: in dentist's chair, paid by scheme
    • Pays shortfalls and co-payments for in-hospital dentistry treatment approved by scheme
    Orthodontics:
    • Paid from day-to-day benefit, 9-18 yrs only
    • No extra benefit available
    Maxillo Facial Surgery:
    • Paid from day-to-day 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)

    No phone calls!
    Our quote will include the right gap cover for this plan

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    MEDICATION:
    Dimension Prime 2 Network
    Scheme Benefits Gap benefits
    Chronic:
    • PMB chronic: paid by scheme
    • non-PMBs: paid from day-to-day benefit
    • No benefit
    Acute (presrcibed) medication:
    • Paid from day-to-day benefit
    • No benefit
    Over-the-counter:
    • Paid from day-to-day benefit
    • No benefit
    Birth Control:
    • Paid from day-to-day benefit
    • No benefit
    On Discharge:
    • Paid from day-to-day benefit
    • No benefit
    Biological:
    • No benefit

    No phone calls!
    Our quote will include the right gap cover for this plan

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    OPTOMETRY:
    Dimension Prime 2 Network
    Scheme Benefits Gap benefits
    Optometry:
      Paid from day-to-day benefit
    • 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)

    No phone calls!
    Our quote will include the right gap cover for this plan

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    MENTAL HEALTH:
    Dimension Prime 2 Network
    Scheme Benefits Gap benefits
    In-hospital:
    • R22,100 per person and R30,300 per family
    • Includes in and out of hospital treatment with psychiatrist
    • No benefit
    Out-of-hospital:
    • Psychiatry: See above
    • Psychology: paid from day-to-day benefit
    • No benefit
    Trauma:
    • Netcare 911 phoneline
    • No benefit

    No phone calls!
    Our quote will include the right gap cover for this plan

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    OTHER BENEFITS:
    Dimension Prime 2 Network
    Scheme Benefits Gap benefits
    General Appliances:
    • Medical Appliances and CPAP apparatus: paid from day-to-day savings
    • Hyperbaric oxygen: R580 per family
    • Stoma products and urine bags: paid by scheme
    • No benefit
    1.1. Hearing Aids:
    • Paid from day-to-day benefit
    • No benefit
    1.2. Wheelchairs:
    • Paid from day-to-day benefit
    • No benefit
    Dialysis:
    • Unlimited
    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: R1,900 per event
    • Transport by air outside RSA: R12,400 per event
    • No benefit
    Other:
    • Oxygen out-of-hospital: Unlimited, at 100% scheme rate
    • No benefit

    No phone calls!
    Our quote will include the right gap cover for this plan

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    WELLNESS/PREVENTATIVE BENEFITS:
    Dimension Prime 2 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

    No phone calls!
    Our quote will include the right gap cover for this plan

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    PROSTHETICS:
    Dimension Prime 2 Network
    Scheme Benefits Gap benefits
    Overal Limit: Most non-PMB sublimits are increased by gap cover, if authorised by medical aid
    • EVARS prosthesis: R118,100
    • Vascular/cardiac prosthesis: R50,600
    • Health-essential functional prosthesis: R56,000. This includes non-PMB hip, knee and shoulder replacements, with no benefit for wear and tear
    • Intra-ocular lenses: R3,800 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): R8,750 per family per year
    • External breast prostheses, (in and out of hospital): from day-to-day benefit
    • Cochlear implants: No benefit
    • Sublimit increased by up to R150,000 per person
    • No benefit for procedures excluded by medical aid
    Sub-limits:
    • 100% scheme rate
    • Sublimit increased by up to R150,000 per person
    • No benefit for procedures excluded by medical aid

    No phone calls!
    Our quote will include the right gap cover for this plan


      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