Medshield MediCore medical aid plan: 2017

Out-of-hospital, scheme pays for some: specialised radiology, maternity, optometry, some non-surgical procedures including scopes, 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:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,926 R1,623 R438
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, optometry, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Hospital Choice:
  • Network
Specialised Radiology:
  • 1 scan per family, with 10% co-payment
Supplementary Services: (Physio, etc)
  • Physiotherapy: Unlimited
Transplants:
Co-payments:
  • Hernia repair: R3,000
  • Diagnostic laparoscopy: R2,000
  • Reflux: R5,000
  • Hysterectomy: R5,000
  • Functional nasal surgery: R5,000
  • Back surgery: R5,000
  • Scopes: R1,500, in hospital
Alternatives to hospitals:
  • Physical rehabilitation, sub-acute facilities, nursing services, hospice: R30,000 per family

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • 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
  • Otherwise, no benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,926 R1,623 R438
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, optometry, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Specialists consultations:
  • 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
  • Otherwise, no benefit
Pathology:
  • No benefit, unless PMB
General radiology:
  • No benefit, unless PMB
Specialised radiology:
  • No benefit, unless PMB
Supplementary Services: (Physio, etc)
  • No benefit, unless PMB

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MATERNITY BENEFITS:
Hospital stay:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,926 R1,623 R438
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, optometry, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Consultations:
  • 6 consults, paid by scheme
  • 4 post-natal consults with midwife, paid by scheme
Scans:
  • 2 x 2D scans

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • PMBs only
  • 6 visits per family from social worker, for psychological support during treatment
  • 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.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,926 R1,623 R438
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, optometry, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from extended fund or 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:unlimited, including in-hospital for under 6yr olds. Paid by scheme.
  • Specialised dentistry: no benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,926 R1,623 R438
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, optometry, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Orthodontics:
  • No benefit
Maxillo Facial Surgery:

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MEDICATION:
Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,926 R1,623 R438
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, optometry, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Acute (presrcibed) medication:
  • No benefit
Over-the-counter:
  • No benefit
Birth Control:
  • R140 per monthly script
On Discharge:
  • R300 per admission
Notes:
  • PMB: Basic formulary
  • Out of formulary PMB or obtained from non-network provider: 40% co-payment
  • PMB: reimbursed at Maximum Generic Price

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OPTOMETRY:
Optometry:
  • No benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,926 R1,623 R438
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, optometry, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from extended fund or 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:
  • R30,000 per family, in the hospital network
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,926 R1,623 R438
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, optometry, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:


Out-of-hospital:

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OTHER BENEFITS:
General Appliances:
  • Stoma products: Unlimited
  • CPAP apparatus: PMBs only
  • Oxygen therapy equipment:
    • PMBs only
  • Ventilators: PMBs only
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,926 R1,623 R438
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, optometry, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

1.1. Hearing Aids:
  • No benefit
1.2. Wheelchairs:
  • No benefit
Dialysis:
HIV:
  • Since HIV is a PMB certain out-of-hospital benefits are automatically covered by all schemes according to protocols
Emergency Transport:
International Coverage:
Other:

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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: R1,926 R1,623 R438
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, optometry, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Pneumonia vaccines:
  • Covered
    • 60yrs+
Back Rehabilitation Programme:
Biometric Screening:
  • Covered
Child Immunisation:
  • Covered
Pap Smear:
  • Covered
Mammogram:
  • Covered for 40yrs+, every 2 years.
PAS Test:
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: R1,926 R1,623 R438
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, optometry, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from extended fund or 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