Medihelp Necesse A medical aid plan: 2019

View all plans in this scheme.
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.

Necesse A
2018 Costs:
Total Cost pm:

Main member:

R474

Adult:

R474

Child: Pay for all under 21yrs

R474
Savings Account:
  • No savings option on this plan
2019 Costs:
Total Cost pm:

Main member:

R529
(11.60%)

Adult:

R529

Child: Pay for all under 21yrs

R529
Savings (per year):
  • No savings option on this plan
Income band:
Need help?
NEW! Are you on this plan?

We can help you determine whether this is still the best plan for you, and offer you some options to consider, if applicable. This is a free, online and personalised service, available to members who do not have a broker. Please click here to start.
In brief (2018):
  • This plan is for full time students earning less than R400pm only
  • 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:
Necesse A
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
  • No benefit, unless PMB
Specialised Radiology:
  • R15,000 per family
  • In and out of hospital
  • Sublimits increased for procedures approved by medical aid
  • Out of hospital, sublimits increased for MRIs and CT scans only
  • Supplementary Services: (Physio, etc)
    • Physiotherapy and occupational therapy: R9,350 per family
    • Sublimits increased for procedures approved by medical aid
    Transplants:
    • PMBs only
    • Cornea implants: R27,400 per implant
    • No extra benefit available (PMB benefits are paid in full by medical aid)
    • Sublimits increased as necessary
    Co-payments:
    • N/A
    • N/A
    Alternatives to hospitals:
    • Private nursing and sub-acute care: R21,200 per family, subject to authorisation.
    • No benefit, unless PMB
    Casualty:
    • Unlimited for PMBs, otherwise 80% of scheme rate up to R1,050 per person and R2,150 per family
    • Radiology 65% scheme rate and forms part of above limit
    • Pathology 100% rate, separate from above limit
    • Excludes facility fee
    • Pays up to R20,000 per person per year for emergency medical treatment not paid for by medical aid
    Other:
    • Robotic assisted laparoscopic procedure: R105,400 per person
    • Pathology, standard radiology and clinical technologist services: R29,000 per family
    • 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)
    We will email you a quote for this and two other comparable plans. FREE.
    We can help you with unpaid claims, finding a gap, general advice, plan changes, cheaper options and more. FREE.

    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.

    .
    .
    .
    .
    OUT OF HOSPITAL BENEFITS (non-PMB):
    Necesse A
    Scheme Benefits Gap benefits
    Main: Adult: Child:
    Savings /yr: No savings option on this plan
    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:
    • Network GP: 9 consults per person
    • . Thereafter PMBs only.
    • No benefit, unless PMB
    Childcare: 2019 Benefits coming November 9, 2018
    • No extra benefit available
    Specialists consultations:
    • Specialist care (consult and treatment or intervention): R2,950 per person and R3,050 per family
    • This benefit covers specialist consultations, surgical and non-surgical procedures, endoscopic procedures, radiology interventions, pathology, acute medicine
    • No benefit, unless PMB
    Pathology:
    • Paid by scheme
    • No benefit, unless PMB
    General radiology:
    • Paid by scheme
    • No benefit, unless PMB
    Specialised radiology:
    • R15,700 per family, in and out of hospital
    • Sublimit increased as necessary for MRI and CT scans
    Supplementary Services: (Physio, etc)
      Physiotherapy and Occupational therapy: R1,950 per person and R3,050 per family
    • No benefit, unless PMB
    We will email you a quote for this and two other comparable plans. FREE.
    We can help you with unpaid claims, finding a gap, general advice, plan changes, cheaper options and more. FREE.
    .
    .
    MATERNITY BENEFITS:
    Necesse A
    Scheme Benefits Gap benefits
    Hospital stay:
    • Hospital delivery: 100% scheme rate
    • Elective C-section: R25,000
    • Home delivery: R12,400
    • Pays up to 500% scheme rate for specialists, GPs and other medical professionals, in-hospital only
    • In-hospital sublimits increased as necessary
    Consultations:
    • GP: 9 consults, shared with GP benefit.
    • Midwife service, pre and post natalcare: Unlimited
    • No benefit, unless PMB
    Scans:
    • No additional benefit
    2019 Benefits coming November 9, 2018
    We will email you a quote for this and two other comparable plans. FREE.
    We can help you with unpaid claims, finding a gap, general advice, plan changes, cheaper options and more. FREE.
    .
    .
    CANCER (ONCOLOGY):
    Necesse A
    Scheme Benefits Gap benefits
    Overall coverage (in and out of hospital):
    • PMBs only
    • Designated Service Provider: ICON
    • 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
    We will email you a quote for this and two other comparable plans. FREE.
    We can help you with unpaid claims, finding a gap, general advice, plan changes, cheaper options and more. FREE.
    .
    .
    DENTISTRY:
    Necesse A
    Scheme Benefits Gap benefits
    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
    • Pays shortfalls and co-payments for in-hospital dentistry treatment approved by scheme
    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
    • 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)
    We will email you a quote for this and two other comparable plans. FREE.
    We can help you with unpaid claims, finding a gap, general advice, plan changes, cheaper options and more. FREE.
    .
    .
    MEDICATION:
    Necesse A
    Scheme Benefits Gap benefits
    Chronic:
    • Conditions covered:27 CDL conditions
    • Co-payment for use of non-formulary:
    • No benefit, unless PMB
    Acute (presrcibed) medication:
    • If dispensed by GP: 100% of scheme rate
    • If dispensed by pharmacy: 100% of MMAP (maximum medical aid price)
    • No benefit, unless PMB
    Over-the-counter:
    • R100 per event, R280 per person per year
    • No benefit, unless PMB
    Birth Control: 2019 Benefits coming November 9, 2018
    • 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
    We will email you a quote for this and two other comparable plans. FREE.
    We can help you with unpaid claims, finding a gap, general advice, plan changes, cheaper options and more. FREE.
    .
    .
    OPTOMETRY:
    Necesse A
    Scheme Benefits Gap benefits
    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
    • 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)
    We will email you a quote for this and two other comparable plans. FREE.
    We can help you with unpaid claims, finding a gap, general advice, plan changes, cheaper options and more. FREE.
    .
    .
    MENTAL HEALTH:
    Necesse A
    Scheme Benefits Gap benefits
    In-hospital: 2019 Benefits coming November 9, 2018
    • No benefit, unless PMB
    Out-of-hospital:
    • PMBs only
    • No benefit, unless PMB
    Trauma:
    • Netcare 911 phoneline
    • No benefit, unless PMB
    We will email you a quote for this and two other comparable plans. FREE.
    We can help you with unpaid claims, finding a gap, general advice, plan changes, cheaper options and more. FREE.
    .
    .
    OTHER BENEFITS:
    Necesse A
    Scheme Benefits Gap benefits
    General Appliances:
    • PMB cases: back, leg, arm and neck supports, crutches, orthopaedic footwear, elastic stockings, peakflow meters, nebulisers: 100% scheem rate
    • CPAP: R9,250 per person every 24 months
    • No benefit
    1.1. Hearing Aids:
    • No benefit, unless PMB
    • No benefit
    1.2. Wheelchairs:
    • R4,500 per family, every 3 years
    • No benefit
    Dialysis:
    • PMBs only
    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: 2019 Benefits coming November 9, 2018
    • No benefit
    Other:
    • Oxygen out-of-hospital: paid by scheme
    • No benefit, unless PMB
    We will email you a quote for this and two other comparable plans. FREE.
    We can help you with unpaid claims, finding a gap, general advice, plan changes, cheaper options and more. FREE.
    .
    .
    WELLNESS/PREVENTATIVE BENEFITS:
    Necesse A
    Scheme Benefits Gap benefits
    Flu vaccination:
    • Covered, from over-the-counter medicine benefit
    • No benefit
    Pneumonia vaccines:
    • No benefit, unless PMB
    • No benefit
    Back Rehabilitation Programme:
    • Covered
    • No benefit
    Biometric Screening:
    • Covered
    • No benefit
    Child Immunisation:
    • No benefit, unless PMB
    • No benefit
    Pap Smear:
    • Covered
    • No benefit
    Mammogram:
    • Covered, 40yrs+
    • No benefit
    PAS Test:
    • Covered, 40yrs+
    • No benefit
    HIV Test:
    • Covered
    • No benefit
    Other:
    • Bone density, 50yrs+
    • Tetanus vaccine or flu vaccine option
    • No benefit
    We will email you a quote for this and two other comparable plans. FREE.
    We can help you with unpaid claims, finding a gap, general advice, plan changes, cheaper options and more. FREE.
    .
    .
    PROSTHETICS:
    Necesse A
    Scheme Benefits Gap benefits
    Overal Limit:
    • Evars prosthesis, vascular/cardiac prosthesis, health-essential prosthesis: R21,900 per person
    • Intra-ocular lenses, prosthesis with reconstructive or restorative surgery, external breast prosthesis: PMBs only
    • Sublimit increased by up to R150,000 per person
    • No benefit for procedures excluded by medical aid
    Sub-limits: 2019 Benefits coming November 9, 2018
    • Sublimit increased by up to R150,000 per person
    • No benefit for procedures excluded by medical aid
    We will email you a quote for this and two other comparable plans. FREE.
    We can help you with unpaid claims, finding a gap, general advice, plan changes, cheaper options and more. FREE.

      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