Medshield MediBonus medical aid plan: 2017

Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB. Pay for three children only.

View all plans in this scheme

IN HOSPITAL PROCEDURES:

Payout Rate for Specialists:

200% scheme rate or agreed cost

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Total Cost:	R4,119	R2,829	R819
Children:	Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-
Extended Fund:	RM =R9,300 M1 = R13,040 M2 =R14,460 M3 = R15,930 M4 = R17,240	R	R

Compare with these plans:

Medshield Premium Plus 2017

Hospital Choice:

Network

Specialised Radiology:

R18,030 per family, with 10% co-payment in and out of hospital

Supplementary Services: (Physio, etc)

Physiotherapy: Unlimited

Transplants:

Unlimited

Co-payments:

Alternatives to hospitals:

Physical rehabilitation, sub-acute facilities, nursing services, hospice: R70,000 per family

.
.

OUT OF HOSPITAL BENEFITS:

GP consultations:

Paid from day-to-day benefit
Breast fine needle biopsy, vasectomy, prostate needle biopsy, circumcision: paid by scheme if done in rooms
Scopes: most paid by scheme if done in rooms

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Total Cost:	R4,119	R2,829	R819
Children:	Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-
Extended Fund:	RM =R9,300 M1 = R13,040 M2 =R14,460 M3 = R15,930 M4 = R17,240	R	R

Compare with these plans:

Medshield Premium Plus 2017

Specialists consultations:

Paid from day-to-day benefit
Breast fine needle biopsy, vasectomy, prostate needle biopsy, circumcision: paid by scheme if done in rooms
Scopes: most paid by scheme if done in rooms

Pathology:

Paid from day-to-day benefit

General radiology:

Paid from day-to-day benefit
1 Bone densitometry scan per person

Specialised radiology:

R18,030 per family, with 10% co-payment for non-PMBs
In and out of hospital

Supplementary Services: (Physio, etc)

Paid from day-to-day benefit

.
.

MATERNITY BENEFITS:

Hospital stay:

200% scheme tariff

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Total Cost:	R4,119	R2,829	R819
Children:	Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-
Extended Fund:	RM =R9,300 M1 = R13,040 M2 =R14,460 M3 = R15,930 M4 = R17,240	R	R

Compare with these plans:

Medshield Premium Plus 2017

Consultations:

12 consults
Antenatal classes: R500 per family
4 post-natal consultations with midwife
Paid by scheme

Scans:

2x 2D scans
1x Amniocentesis
Paid by scheme

.
.

CANCER (ONCOLOGY):

Overall coverage (in and out of hospital):

R450,000 per family
Biological medicine: R180,000, subject to above limit
6 visits per family from social worker, for psychological support during treatment
Macular degeneration: R40,000 per family
Breast reconstruction: R80,000 per family

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.

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Total Cost:	R4,119	R2,829	R819
Children:	Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-
Extended Fund:	RM =R9,300 M1 = R13,040 M2 =R14,460 M3 = R15,930 M4 = R17,240	R	R

Compare with these plans:

Medshield Premium Plus 2017

.
.

DENTISTRY:

Dentistry:

Standard dentistry:unlimited, including in-hospital for under 6yr olds. Paid by scheme.
Specialised dentistry: R15,000 per family for wisdom teeth, implants, orthodontic treatment, crowns, bridges, inlays, periodontics etc. Paid by scheme.

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Total Cost:	R4,119	R2,829	R819
Children:	Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-
Extended Fund:	RM =R9,300 M1 = R13,040 M2 =R14,460 M3 = R15,930 M4 = R17,240	R	R

Compare with these plans:

Medshield Premium Plus 2017

Orthodontics:

See above

Maxillo Facial Surgery:

R15,900 per family, at 200% scheme rate

.
.

MEDICATION:

Chronic:

PMBs chronic: paid by scheme
non-PMBs: Additional 54 conditions covered
R11,910 per person and R23,815 per family, thereafter unlimited for PMBs

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Total Cost:	R4,119	R2,829	R819
Children:	Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-
Extended Fund:	RM =R9,300 M1 = R13,040 M2 =R14,460 M3 = R15,930 M4 = R17,240	R	R

Compare with these plans:

Medshield Premium Plus 2017

Acute (presrcibed) medication:

Paid from day-to-day benefit

Over-the-counter:

Limited to M= R725 and M1+= R1,245 with R185 limit per script. From day-to-day benefit.

Birth Control:

R140 per monthly script
Mirena: one per female every four years. Includes consultation, insertion if done in rooms.

On Discharge:

R700 per admission

Notes:

PMB: Comprehensive formulary within limits, then Restrictive formulary
Out of formulary PMB or obtained from non-network provider: 40% co-payment
PMB: reimbursed at Maximum Generic Price

.
.

OPTOMETRY:

Optometry:

R2,675 per person, every 2 years
Paid by scheme
Refractive surgery: R15,400 per family

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Total Cost:	R4,119	R2,829	R819
Children:	Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-
Extended Fund:	RM =R9,300 M1 = R13,040 M2 =R14,460 M3 = R15,930 M4 = R17,240	R	R

Compare with these plans:

Medshield Premium Plus 2017

.
.

MENTAL HEALTH:

In-hospital:

R35,000 per family, in the hospital network, in and out-of-hospital

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Total Cost:	R4,119	R2,829	R819
Children:	Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-
Extended Fund:	RM =R9,300 M1 = R13,040 M2 =R14,460 M3 = R15,930 M4 = R17,240	R	R

Compare with these plans:

Medshield Premium Plus 2017

Out-of-hospital:

R35,000 per family, in the hospital network, in and out-of-hospital

.
.

OTHER BENEFITS:

General Appliances:

R11,500 per family
Peak flow meters, nebulizers, glucometers and blood pressure monitors: R750 per person, subject to above limit
Stoma products: Unlimited
Oxygen therapy equipment and home ventilators: Unlimited

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Total Cost:	R4,119	R2,829	R819
Children:	Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-
Extended Fund:	RM =R9,300 M1 = R13,040 M2 =R14,460 M3 = R15,930 M4 = R17,240	R	R

Compare with these plans:

Medshield Premium Plus 2017

1.1. Hearing Aids:

See "General Appliances" limit

1.2. Wheelchairs:

See "General Appliances" limit

Dialysis:

Unlimited

HIV:

Since HIV is a PMB certain out-of-hospital benefits are automatically covered by all schemes according to protocols

Emergency Transport:

International Coverage:

Up to R500,000 per person per journey, with R350,000 limit on pre-existing conditions

Other:

.
.

WELLNESS/PREVENTATIVE BENEFITS:

Flu vaccination:

Covered

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Total Cost:	R4,119	R2,829	R819
Children:	Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-
Extended Fund:	RM =R9,300 M1 = R13,040 M2 =R14,460 M3 = R15,930 M4 = R17,240	R	R

Compare with these plans:

Medshield Premium Plus 2017

Pneumonia vaccines:

Covered

Back Rehabilitation Programme:

Biometric Screening:

Covered

Child Immunisation:

Covered

Pap Smear:

Covered

Mammogram:

Covered for 40yrs+, every 2 years.

PAS Test:

HIV Test:

Covered

.
.

PROSTHESIS:

Overal Limit:

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Total Cost:	R4,119	R2,829	R819
Children:	Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-
Extended Fund:	RM =R9,300 M1 = R13,040 M2 =R14,460 M3 = R15,930 M4 = R17,240	R	R

Compare with these plans:

Medshield Premium Plus 2017

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