Medihelp Necesse E medical aid plan: 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.

Necesse E
2018 Costs:
Total Cost pm:

Main member:

R2,076

Adult:

R1,620

Child: Pay for all under 21yrs

R900
Savings Account:
  • No savings option on this plan
2019 Costs:
Total Cost pm:

Main member:

R
(%)

Adult:

R

Child: Pay for all under 21yrs

R
Income band:
In brief (2018):
  • 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 E
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:
  • 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: R8,950 per family
    • Sublimits increased for procedures approved by medical aid
    Transplants:
    • PMBs only
    • Cornea implants: R26,100 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: 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
    • 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):
    Necesse E
    Scheme Benefits Gap benefits
    Main: 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.
    • 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
    Childcare:
    • No extra benefit available
    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

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

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    MATERNITY BENEFITS:
    Necesse E
    Scheme Benefits Gap benefits
    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
    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

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

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    CANCER (ONCOLOGY):
    Necesse E
    Scheme Benefits Gap benefits
    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

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

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    DENTISTRY:
    Necesse E
    Scheme Benefits Gap benefits
    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
    Orthodontics:
    • You pay this out of pocket
    • No extra benefit available
    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)

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

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    MEDICATION:
    Necesse E
    Scheme Benefits Gap benefits
    Chronic:
    • PMB chronic: paid by scheme, from network pharmacy and according to formulary
    • No benefit
    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

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

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    OPTOMETRY:
    Necesse E
    Scheme Benefits Gap benefits
    Optometry:
    • Eye test: one every 2 years
    • Frames: R200 every 2 years
    • Lenses: Every 2 years
    • Contacts: R450 per person every 2 years
    • 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:
    Necesse E
    Scheme Benefits Gap benefits
    In-hospital:
    • PMBs only
    • No benefit
    Out-of-hospital:
    • PMBs only
    • 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:
    Necesse E
    Scheme Benefits Gap benefits
    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
    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:
    • Netcare 911
    • No benefit
    International Insurance: 2018 benefits coming soon!
    • No benefit
    Other:
    • Oxygen out-of-hospital: Unlimited, at 100% 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.

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

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    WELLNESS/PREVENTATIVE BENEFITS:
    Necesse E
    Scheme Benefits Gap benefits
    Flu vaccination:
    • Covered
    • No benefit
    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

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

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    PROSTHETICS:
    Necesse E
    Scheme Benefits Gap benefits
    Overal Limit:
    • An additional R40,000 per sublimit, per event
    Sub-limits:
    • An additional R40,000 per sublimit, per event

    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