Medihelp Necesse E medical aid plan: 2017 vs 2018

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.

COSTS and OVERVIEW:
Necesse E
2018 costs In brief:
What’s new in 2018?
Main: Adult: Child:
Cost 2018: R2,076 R1,620 R900
Cost 2017: (R1,932) (R1,506) (R834)
Gap (optional): KaeloXelus: R350 per family
(R600 per family if anyone is 60yrs+)
Overal Limit: Unlimited overall, with sub-limits
PMBs: Day-to-day expenses for PMBs (eg. cancer) are always paid for by the scheme, according to protocols. Find out more
Savings: No savings option on this plan
Children: Pay for all children
Income band: This plan is only available to households with income in R11,001+pm band.
View other income bands

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Avoid bills! Get up to: 800% scheme rate;  R12,800 per ER visit; unlimited cancer cover;  

co-payments paid and cash payout for hospital stay. R350pm per family


IN HOSPITAL PROCEDURES:
Necesse E
2017 v 2018 benefits Gap benefits Notes
Payout Rate for Specialists: Fusion Gap:
  • Up to 600% scheme rate for specialists and other providers
  • In case of admission related to accident:
    -R300 per day, for days 1-13
    -R600 per day for days 14-20
    -R1,200 per day for days 21-30
  • R350pm per family. More Info or download application below.

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Hospital Choice:
  • Network hospitals
Fusion Gap:
  • R12,800 per person per year for use of a non-network hospital
Specialised Radiology:
  • Co-payment: none
  • Sublimit: R15,000 per family
  • Rate: 100% scheme rate
  • In and out of hospital
Supplementary Services: (Physio, etc)
  • Physiotherapy and occupational therapy: R8,950 per family
Fusion Gap:
  • Up to 600% scheme rate for specialists and other providers
Transplants:
  • PMBs only
  • Cornea implants: R26,100 per implant
Co-payments:
  • N/A
  • N/A
Alternatives to hospitals:
  • Private nursing and sub-acute care: R20,200 per family, subject to authorisation.
  • No benefit
Casualty:
  • Unlimited for PMBs, otherwise 80% of scheme rate up to R1,000 per person and R2,050 per family
  • Excludes facility fee and radiology
  • Casualty costs not covered by medical aid, in case of emergency treatment: R12,800 per incident. Cover also applies to costs covered by savings account.
Other:
  • Conventional appendectomy and prostatectomy: paid by scheme
  • Laparoscopic appendectomy: R15,800 per person
  • Robotic assisted laparoscopic procedure: R100,400 per person
  • Pathology and standard radiology: R27,700 per family
  • Clinical Technologist Services: R20,200
  • Up to 500% of scheme rate
  • Certain in-hospital sublimits increased by R44,000 per event, unlimited for the year
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OUT OF HOSPITAL BENEFITS:
Necesse E
2017 v 2018 benefits Gap benefits Notes
GP consultations:
  • Network GP: 9 consults per person
  • . Thereafter PMBs only.
  • Out of hospital treatment for conditions that are PMBs is always paid for by the scheme (not out of savings), but according to protocols
  • No benefit


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Childcare:
  • No benefit
Specialists consultations:
  • Specialist care (consult and treatment or intervention): R2,950 per person and R4,100 per family
  • This benefit covers specialist consultations, surgical and non-surgical procedures, endoscopic procedures, radiology interventions, pathology, acute medicine
  • No benefit
Pathology:
  • Paid by scheme
  • No benefit
General radiology:
  • Paid by scheme
  • No benefit
Specialised radiology:
  • R15,000 per family, in and out of hospital
  • No benefit
Supplementary Services: (Physio, etc)
    Physiotherapy and Occupational therapy: R1,900 per person and R2,800 per family
  • No benefit
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MATERNITY BENEFITS:
Necesse E
2017 v 2018 benefits Gap benefits Notes
Hospital stay:
  • 100% scheme rate
  • >R 23,900 for elective caesarean section Home delivery: R11,900
  • Premature birth, more than 6 weeks:R12,000 lump payment
  • In case of admission related to premature birth:
    • R300 per day, for days 1-13
    • R600 per day for days 14-20
    • R1,200 per day for days 21-30

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Consultations:
  • GP: 9 consults, shared with GP benefit.
  • Gynaecologist: 2 consults
  • Midwife service, pre and post natalcare: Unlimited
  • No benefit
Scans:
  • 2 x 2D scans, paid by scheme
  • No benefit
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CANCER (ONCOLOGY):
Necesse E
2017 v 2018 benefits Gap benefits Notes
Overall coverage (in and out of hospital):
  • 100% of cost, in and out-of-hospital, subject to treatment approval
  • Designated Service Provider: ICON
  • No benefit
All oncology benefits are assessed on a case-by-case basis, and are subject to protocols, preferred providers and scheme rules. Benefit covers out-of-hospital treatment too, like chemotherapy.
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DENTISTRY:
Necesse E
2017 v 2018 benefits Gap benefits Notes
Dentistry:
  • Standard Dentistry: paid by scheme.
  • Includes:
    • 2 annual checkups
    • X-rays. (Extra-oral 1 every 3 years)
    • 1 annual scale or polish treatments per person
    • 4 fillings per person per year
    • Extractions and root canals
    • Plastic dentures, 1 set per family every 2 years
  • Specialised dentistry:
    • Conscious sedation in rooms: for extensive treatment only
  • Dental reconstruction due to due to trauma or oncology treatment: R40,000 per event
  • Full cover for in-hospital co-payments

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Orthodontics:
  • No benefit
  • No benefit
Maxillo Facial Surgery:
  • No benefit, unless PMB
  • Dental reconstruction as result of trauma or oncology: R40,000 per event

Avoid bills! Get up to: 800% scheme rate;  R12,800 per ER visit; unlimited cancer cover;  

co-payments paid and cash payout for hospital stay. R350pm per family

MEDICATION:
Necesse E
2017 v 2018 benefits Gap benefits Notes
Chronic:
  • PMB chronic: paid by scheme, from network pharmacy and according to formulary
  • No benefit

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Acute (presrcibed) medication:
  • If dispensed by GP: 100% of scheme rate
  • If dispensed by pharmacy: 100% of MMAP
  • No benefit
Over-the-counter:
  • R100 per event, R270 per person per year
  • No benefit
Birth Control:
  • No benefit
On Discharge:
  • R330 per admission
  • No benefit
Biological:
  • No benefit
  • No benefit
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OPTOMETRY:
Necesse E
2017 v 2018 benefits Gap benefits Notes
Optometry:
  • Eye test: one every 2 years
  • Frames: R200 every 2 years
  • Lenses: Every 2 years
  • Contacts: R450 per person every 2 years
  • No benefit

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MENTAL HEALTH:
Necesse E
2017 v 2018 benefits Gap benefits Notes
In-hospital:
  • PMBs only
  • No benefit

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Out-of-hospital:
  • PMBs only
  • No benefit
Trauma:
  • Netcare 911 phoneline
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OTHER BENEFITS:
Necesse E
2017 v 2018 benefits Gap benefits Notes
General Appliances:
  • Medical, surgical and orthopaedic appliances, external breast prostheses (PMB only): R9,000 per family
  • CPAP: R8,850 per person every 24 months
  • No benefit

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1.1. Hearing Aids:
  • See "General Appliances"
  • No benefit
1.2. Wheelchairs:
  • See "General Appliances"
  • No benefit
Dialysis:
  • PMBs only
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:
  • No benefit
International Insurance: 2018 benefits coming soon!
  • No benefit
Other:
  • Oxygen out-of-hospital: Unlimited, at100% scheme rate
  • Death or permanent disability: R12,000. If cause of death was accidental: R24,000.
  • If Principal member of medical aid passes away or becomes disabled: Medical aid contributions will be paid for six months, up to R4,400 per month. Gap premium is also waived for 6 months
  • In event of vehicle accident where policy holder was not at fault: Gap will provide all legal assistance, fully covered.
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WELLNESS/PREVENTATIVE BENEFITS:
Necesse E
2017 v 2018 benefits Gap benefits Notes
Flu vaccination:
  • Covered
  • No benefit

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Pneumonia vaccines:
  • No benefit
  • No benefit
Back Rehabilitation Programme:
  • Covered
  • No benefit
Biometric Screening:
  • Covered
  • No benefit
Child Immunisation:
  • No benefit
  • 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

Avoid bills! Get up to: 800% scheme rate;  R12,800 per ER visit; unlimited cancer cover;  

co-payments paid and cash payout for hospital stay. R350pm per family

2017 v 2018 benefits Gap benefits Notes
Overal Limit:
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Sub-limits:
  • An additional R40,000 per sublimit, per event

    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