Medihelp Plus medical aid plan: 2017

Out-of-hospital, scheme pays for some: specialised radiology, maternity, medical appliances, GPs, specialists, psychologists, supplementary health, medication, radiology and pathology, dentistry and optometry. All else paid from out of pocket, unless PMB. Pay for all children. .

View all plans in this scheme

IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,936 R6,936 R1,728
Children: Pay for all children.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, medical appliances, GPs, specialists, psychologists, supplementary health, medication, radiology and pathology, dentistry and optometry. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Hospital Choice:
  • Unlimited
Specialised Radiology:
  • MRI, CT and Angiography: unlimited, in and out of hospital
  • PET Scans: R19,100 per case (non-PMB)
Supplementary Services: (Physio, etc)
  • 100% scheme rate
  • In addition, scheme covers professional services for up to 30 days after discharge following hospital admission, including speech therapy, occupational therapy and physiotherapy. M =R1,650 and M+ =R2,200
Transplants:
  • Cornea implants: R24,750 per implant
  • Otherwise, unlimited
Co-payments: None
Alternatives to hospitals:
  • Hospice and sub-acute facilities: paid by scheme, subject to authorisation
  • Private nursing: paid by scheme, subject to authorisation

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Consult: R3,100 per person. Shared with GPs, specialists, physiotherapy, supplementary services and ER
  • Treatment (medical and surgical services, anesthesia, material and medicine used during service:Unlimited
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,936 R6,936 R1,728
Children: Pay for all children.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, medical appliances, GPs, specialists, psychologists, supplementary health, medication, radiology and pathology, dentistry and optometry. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Specialists consultations:
  • See GP benefit, above
Pathology:
  • Unlimited.
General radiology:
  • Unlimited
Specialised radiology:
  • Unlimited for MRI, CT and Angiography, in and out of hospital
  • PET scans: R19,100 per case (non-PMB)
  • Paid by scheme
Supplementary Services: (Physio, etc)
  • See GP benefit, above
  • Also, speech therapy, occupational therapy and physiotherapy for up to 30 days after discharge following hospital admission. Limited to R1,650 per person and R2,200 per family

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MATERNITY BENEFITS:
Hospital stay:
    Hospital delivery:
  • 100% scheme rate
  • Home delivery: R11,350
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,936 R6,936 R1,728
Children: Pay for all children.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, medical appliances, GPs, specialists, psychologists, supplementary health, medication, radiology and pathology, dentistry and optometry. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Consultations:
  • 12 consults, paid by scheme
  • 2 paediatric consults, paid by scheme
Scans:
  • 2 x 2D scans, paid by scheme

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • 100% of cost, in and out-of-hospital, subject to treatment approval
  • ICON enhanced protocol
  • 10% co-payments apply for non-network services and/or deviating from protocol
  • Wigs: R1,650 every three years

Note: 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.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,936 R6,936 R1,728
Children: Pay for all children.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, medical appliances, GPs, specialists, psychologists, supplementary health, medication, radiology and pathology, dentistry and optometry. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

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DENTISTRY:
Dentistry:
  • Standard dentistry: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,936 R6,936 R1,728
Children: Pay for all children.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, medical appliances, GPs, specialists, psychologists, supplementary health, medication, radiology and pathology, dentistry and optometry. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Orthodontics:
  • R13,500 per person per lifetime, 9-18 yrs only
Maxillo Facial Surgery:
  • paid by scheme

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MEDICATION:
Chronic:
  • PMB chronic: paid by scheme
  • non-PMBs chronic medicine: R15,600 per person. 100% of MMAP if generic.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,936 R6,936 R1,728
Children: Pay for all children.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, medical appliances, GPs, specialists, psychologists, supplementary health, medication, radiology and pathology, dentistry and optometry. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Acute (presrcibed) medication:
  • R5,350 per person, pooled per family.
Over-the-counter:
  • See "Acute Medicine" benefit
Birth Control:
  • See "Acute Medicine" benefit, above
On Discharge:
  • R510 per admission
Notes:
  • PMBs chronic: only 40% of the reference price is paid if medicine is outside the formulary and/or obtained from non-network provider
  • For acute and non-PMBs chronic medicines:
    • 80% of scheme rate where no generic is available
    • 70% of MMAP (maximum medical aid price) for voluntary use of original medicine where generic is available

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OPTOMETRY:
Optometry:
  • Eye test: one every 2 years
  • Frames: R750 every 2 years
  • Lenses: Every 2 years
  • Contacts: R1,660 per person every 2 years
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,936 R6,936 R1,728
Children: Pay for all children.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, medical appliances, GPs, specialists, psychologists, supplementary health, medication, radiology and pathology, dentistry and optometry. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
  • R36,950 per person and R50,350 per family
  • Includes in and out of hospital treatment
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,936 R6,936 R1,728
Children: Pay for all children.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, medical appliances, GPs, specialists, psychologists, supplementary health, medication, radiology and pathology, dentistry and optometry. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:


Out-of-hospital:
  • Psychology consultations and psychiatric nursing: R3,100 per person. Shared with GPs, Specialists, Physiotherapy, Supplementary Services and ER
  • paid by scheme

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    OTHER BENEFITS:
    General Appliances:
    • Insulin pumps, glucometers, medical appliances and hyperbaric oxygen: R1,650 per person
    • Stoma products and urine bags: paid by scheme
    • Wigs: R1,650 every three years
    • CPAP apparatus: R8,400 per person every two years
    Overall Annual Limit (OAL):
    Unlimited overall, with sub-limits
    Contributions:
    Main: Adult: Child:
    Total Cost: R6,936 R6,936 R1,728
    Children: Pay for all children.
    Day-to-Day Benefit:
    Out-of-hospital, scheme pays for some: specialised radiology, maternity, medical appliances, GPs, specialists, psychologists, supplementary health, medication, radiology and pathology, dentistry and optometry. All else paid from out of pocket, unless PMB.
    Main: Adult: Child:
    (S) Savings: R0- R0- R0-

    Compare with these plans:

    1.1. Hearing Aids:
    • R13,560 per person every 3 years
    1.2. Wheelchairs:
    • R7,440 per person every 3 years
    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
    Emergency Transport:
    • Netcare 911
    International Coverage:
    Other:
    • Oxygen out-of-hospital: Unlimited, at 100% scheme rate

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    WELLNESS/PREVENTATIVE BENEFITS:
    Flu vaccination:
    • Covered
    Overall Annual Limit (OAL):
    Unlimited overall, with sub-limits
    Contributions:
    Main: Adult: Child:
    Total Cost: R6,936 R6,936 R1,728
    Children: Pay for all children.
    Day-to-Day Benefit:
    Out-of-hospital, scheme pays for some: specialised radiology, maternity, medical appliances, GPs, specialists, psychologists, supplementary health, medication, radiology and pathology, dentistry and optometry. All else paid from out of pocket, unless PMB.
    Main: Adult: Child:
    (S) Savings: R0- R0- R0-

    Compare with these plans:

    Pneumonia vaccines:
    • Covered, 55yrs+
    Back Rehabilitation Programme:
    • Covered
    Biometric Screening:
    • Covered
    Child Immunisation:
    • Covered
    Pap Smear:
    • Covered
    Mammogram:
    • Covered, 40yrs+
    PAS Test:
    • Covered, 40yrs+
    HIV Test:
    • Covered

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    PROSTHESIS:
    Overal Limit:
    Overall Annual Limit (OAL):
    Unlimited overall, with sub-limits
    Contributions:
    Main: Adult: Child:
    Total Cost: R6,936 R6,936 R1,728
    Children: Pay for all children.
    Day-to-Day Benefit:
    Out-of-hospital, scheme pays for some: specialised radiology, maternity, medical appliances, GPs, specialists, psychologists, supplementary health, medication, radiology and pathology, dentistry and optometry. All else paid from out of pocket, unless PMB.
    Main: Adult: Child:
    (S) Savings: R0- R0- R0-

    Compare with these plans:
    Sub-limits:

      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