Medshield MediPhila medical aid plan: 2017

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

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IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
Overall Annual Limit (OAL):
R500,000 per person, R1 million per family for non-PMB
Contributions:
Main: Adult: Child:
Total Cost: R1,041 R1.041 R261
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, 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: R2,500 per family R R

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Hospital Choice:
  • Network
Specialised Radiology:
  • 1 scan per family, with 10% co-payment and subject to overall hospital limit
Supplementary Services: (Physio, etc)
  • Subject to Overall Annual Limit (see above)
Transplants:
Co-payments:
  • Endoscopic procedures: R1,500 co-payment if done in hospital
Alternatives to hospitals:

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Network GP: M= 8 consults, M1= 9 consults, M2+=11 consults. Thereafter, only with authorisation
  • Non-network GP: 2 consults . Thereafter, 40% co-payment subject to above GP consult limits
  • 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
Overall Annual Limit (OAL):
R500,000 per person, R1 million per family for non-PMB
Contributions:
Main: Adult: Child:
Total Cost: R1,041 R1.041 R261
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, 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: R2,500 per family R R

Compare with these plans:

Specialists consultations:
  • Two consultations per family, then from day-to-day benefit
Pathology:
  • Covered if referred by GP
General radiology:
  • Covered if referred by GP
Specialised radiology:
  • 1 scan per family, with 10% co-payment and subject to overall hospital limit. In and out of hospital.
Supplementary Services: (Physio, etc)

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MATERNITY BENEFITS:
Hospital stay:
  • Unlimited
Overall Annual Limit (OAL):
R500,000 per person, R1 million per family for non-PMB
Contributions:
Main: Adult: Child:
Total Cost: R1,041 R1.041 R261
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, 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: R2,500 per family R R

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Consultations:
  • 6 consults, paid by scheme
  • 4 post-natal consults with midwife, paid by scheme
Scans:
  • 2x 2D scans, paid by scheme
  • 1x Amniocentesis, paid by scheme

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • PMBs only
  • 4 visits per family from social worker, for psychological support during treatment
  • Macular degeneration: R20,000 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):
R500,000 per person, R1 million per family for non-PMB
Contributions:
Main: Adult: Child:
Total Cost: R1,041 R1.041 R261
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, 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: R2,500 per family R R

Compare with these plans:

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DENTISTRY:
Dentistry:
  • Standard dentistry: R1,135 per family, paid by scheme
  • Specialised dentistry: R5,000 per family incl wisdom teeth, paid by scheme
  • Crowns, bridges, inlays, dentures, periodontics, models, orthodontics, implants: no benefit
Overall Annual Limit (OAL):
R500,000 per person, R1 million per family for non-PMB
Contributions:
Main: Adult: Child:
Total Cost: R1,041 R1.041 R261
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, 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: R2,500 per family R R

Compare with these plans:

Orthodontics:
Maxillo Facial Surgery:

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MEDICATION:
Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
R500,000 per person, R1 million per family for non-PMB
Contributions:
Main: Adult: Child:
Total Cost: R1,041 R1.041 R261
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, 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: R2,500 per family R R

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Acute (presrcibed) medication:
  • R1,135 per family, from day-to-day benefit
Over-the-counter:
  • Shared with Acute medicine benefit, and limited to M= R285 and M1+= R395 with R60 limit per script
Birth Control:
  • R96 per monthly script
On Discharge:
  • R150 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:
  • R640 per person, every 2 years
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
R500,000 per person, R1 million per family for non-PMB
Contributions:
Main: Adult: Child:
Total Cost: R1,041 R1.041 R261
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, 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: R2,500 per family R R

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
Overall Annual Limit (OAL):
R500,000 per person, R1 million per family for non-PMB
Contributions:
Main: Adult: Child:
Total Cost: R1,041 R1.041 R261
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, 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: R2,500 per family R R

Compare with these plans:


Out-of-hospital:

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OTHER BENEFITS:
General Appliances:
Overall Annual Limit (OAL):
R500,000 per person, R1 million per family for non-PMB
Contributions:
Main: Adult: Child:
Total Cost: R1,041 R1.041 R261
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, 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: R2,500 per family R R

Compare with these plans:

1.1. Hearing Aids:
1.2. Wheelchairs:
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):
R500,000 per person, R1 million per family for non-PMB
Contributions:
Main: Adult: Child:
Total Cost: R1,041 R1.041 R261
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, 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: R2,500 per family R R

Compare with these plans:

Pneumonia vaccines:
Back Rehabilitation Programme:
Biometric Screening:
  • Covered
Child Immunisation:
Pap Smear:
  • Covered
Mammogram:
PAS Test:
HIV Test:
  • Covered

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PROSTHESIS:
Overal Limit:
Overall Annual Limit (OAL):
R500,000 per person, R1 million per family for non-PMB
Contributions:
Main: Adult: Child:
Total Cost: R1,041 R1.041 R261
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, 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: R2,500 per family R R

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