Medihelp Unify medical aid plan: 2019

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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.

Unify
2018 Costs:
Total Cost pm:

Main member:

R2,088

Adult:

R1,716

Child: Pay for all

R624
Savings Account (yr): R6,264 R5,112 R1,800
2019 Costs:
Total Cost pm:

Main member:

R2,304
(10.34%)

Adult:

R1,896

Child: Pay for all

R696
Savings: R6,912 R5,688 R2,088
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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:
Unify
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 any hospital
  • No benefit, unless PMB
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)
    • Up to 100% scheme rate
    • Professional services for up to 30 days after discharge following hospital admission: speech therapy, occupational therapy and physiotherapy. R1,750 per person and R2,400 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:
    • PMBs only
    • Cornea implants: R27,400
    • No extra benefit available (PMB benefits are paid in full by medical aid)
    • Sublimits increased as necessary
    Co-payments:
      Back and neck fusion: R9,950 co-payment
    • Gastroscopy and Colonoscopy:
      • in doctor's rooms: no co-payment, paid from day-to-day benefit
      • in day hospital: R2,650 co-payment
      • in-hospital: R3,700 co-payment
    • Specialised radiology (MRIs and CT Scans): R1,600 co-payment
    • In-hospital dentistry: R3,000 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, unless PMB
    Casualty:
    • From day-to-day benefits
    • Pays up to R20,000 per person per year for emergency medical treatment not paid for by medical aid
    Other:
    • Robotic assisted laparoscopic procedure for prostatectomy: R100,400 per person
    • Neurostimulators: R105,400 per person
    • Hyperbaric oxygen in-hospital: R600 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)
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    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):
    Unify
    Scheme Benefits Gap benefits
    Main: Adult: Child:
    Savings /yr: R6,264 R5,112 R1,800
    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:
      From day-to-day benefit , unless PMB.
    • No benefit, unless PMB
    Childcare: 2019 Benefits coming November 9, 2018
    • No extra benefit available
    Specialists consultations:
      From day-to-day benefit , unless PMB.
    • No benefit, unless PMB
    Pathology:
      From day-to-day benefit , unless PMB.
    • No benefit, unless PMB
    General radiology:
      From day-to-day benefit , unless PMB.
    • No benefit, unless PMB
    Specialised radiology:
    • R1,600 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)
    • Also, speech therapy, occupational therapy and physiotherapy for up to 30 days after discharge following hospital admission. Limited to R1,750 per person and R2,400 per family
    • No benefit, unless PMB
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    MATERNITY BENEFITS:
    Unify
    Scheme Benefits Gap benefits
    Hospital stay:
    • Hospital delivery: 100% scheme rate
    • Home delivery: R12,400
    • Pays up to 500% scheme rate for specialists, GPs and other medical professionals, in-hospital only
    Consultations:
    • From day-to-day benefits
    • No benefit, unless PMB
    Scans:
    • From day-to-day benefits
    2019 Benefits coming November 9, 2018
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    CANCER (ONCOLOGY):
    Unify
    Scheme Benefits Gap benefits
    Overall coverage (in and out of hospital):
    • R220,000 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
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    DENTISTRY:
    Unify
    Scheme Benefits Gap benefits
    Standard Dentistry:
    • Standard dentistry: from day-to-day benefits
    Specialised Dentistry:
    • Specialised dentistry: from day-to-day benefits
    • Pays shortfalls and co-payments for in-hospital dentistry treatment approved by scheme
    In-Hospital Dentistry:
    • Maxilo-facial surgery: No benefit, unless PMB
    Orthodontics:
    • From day-to-day benefits
    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)
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    MEDICATION:
    Unify
    Scheme Benefits Gap benefits
    Chronic:
    • Conditions covered:27 CDL conditions
    • Co-payment for use of non-formulary:
    • No benefit, unless PMB
    Acute (presrcibed) medication:
    • From day-to-day benefit
    • No benefit, unless PMB
    Over-the-counter:
    • From day-to-day benefits
    • No benefit, unless PMB
    Birth Control:
    • From day-to-day benefits
    • No benefit, unless PMB
    On Discharge:
    • From day-to-day benefits
    • No benefit, unless PMB
    Biological:
    • No benefit, unless PMB level of care
    • No benefit, unless PMB
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    OPTOMETRY:
    Unify
    Scheme Benefits Gap benefits
    Optometry:
    Limit:From day-to-day benefit
    Consult:n/a
    Frames:n/a
    Single lensesn/a
    Bifocals:n/a
    Multifocalsn/a
    Contactsn/a
    Refractive Surgery:n/a
    Notes:n/a
    • 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)
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    MENTAL HEALTH:
    Unify
    Scheme Benefits Gap benefits
    In-hospital: 2019 Benefits coming November 9, 2018
    • No benefit, unless PMB
    Out-of-hospital:
    • From day-to-day benefits
    • No benefit, unless PMB
    Trauma:
    • Netcare 911 phoneline
    • No benefit, unless PMB
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    OTHER BENEFITS:
    Unify
    Scheme Benefits Gap benefits
    General Appliances:
    • Medical Appliances, CPAP apparatus and hyperbaric oxygen: paid from day-to-day savings
    • Stoma products and urine bags: paid by scheme
    • No benefit
    1.1. Hearing Aids:
    • From day-to-day benefits
    • No benefit
    1.2. Wheelchairs:
    • From day-to-day benefits
    • 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:
    • Transport by road outside RSA: R1,950 per event
    • Transport by air outside RSA: R13,000 per event
    • No benefit
    Other:
    • Oxygen out-of-hospital: paid by scheme
    • No benefit, unless PMB
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    WELLNESS/PREVENTATIVE BENEFITS:
    Unify
    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:
    • No benefit
    • No benefit
    Mammogram:
    • No benefit
    • No benefit
    PAS Test:
    • No benefit
    • No benefit
    HIV Test:
    • Covered
    • No benefit
    Other: 2019 Benefits coming November 9, 2018
    • No benefit
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    PROSTHETICS:
    Unify
    Scheme Benefits Gap benefits
    Overal Limit: Most non-PMB sublimits are increased by gap cover, if authorised by medical aid
    • EVARS prosthesis: R124,000
    • Vascular/cardiac prosthesis: R53,100
    • Health-essential functional prosthesis: R58,800. This includes non-PMB hip, knee and shoulder replacements, with no benefit for wear and tear
    • Intra-ocular lenses: R3,950 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) or external breast prostheses, (in and out of hospital): R9,150 per family per year
    • External prosthesis: from day-to-day benefit
    • 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
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      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