Makoti Comprehensive C medical aid plan: 2017

Pay for all children. Income-limited plan: R12,251-R16,250pm only

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IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
Overall Annual Limit (OAL):
PMBs only, in private hospitals
Contributions:
Main: Adult: Child:
Total Cost: R1,832 R1,537 R594
Children: Pay for all children
Income limit: R12,251-R16,250 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Hospital Choice:
  • Private hospitals
Specialised Radiology:
  • PMBs only, in private hospitals
Supplementary Services: (Physio, etc)
  • PMBs only, in private hospitals
Transplants:
  • PMBs only, in private hospitals
Co-payments: None
Alternatives to hospitals:

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Chosen network GP: Unlimited
Overall Annual Limit (OAL):
PMBs only, in private hospitals
Contributions:
Main: Adult: Child:
Total Cost: R1,832 R1,537 R594
Children: Pay for all children
Income limit: R12,251-R16,250 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Specialists consultations:
  • Subject to pre-authorisation
Pathology:
  • Basic pathology covered by scheme
General radiology:
  • Basic radiology covered by scheme
Specialised radiology:
  • No benefit, unless PMB
Supplementary Services: (Physio, etc)
  • Physio and occupational therapy: 20 consults per family

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MATERNITY BENEFITS:
Hospital stay:
Overall Annual Limit (OAL):
PMBs only, in private hospitals
Contributions:
Main: Adult: Child:
Total Cost: R1,832 R1,537 R594
Children: Pay for all children
Income limit: R12,251-R16,250 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Consultations:
  • Consults: With network GP
Scans:
  • 2 x 2D scans, paid by scheme

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
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):
PMBs only, in private hospitals
Contributions:
Main: Adult: Child:
Total Cost: R1,832 R1,537 R594
Children: Pay for all children
Income limit: R12,251-R16,250 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

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DENTISTRY:
Dentistry:
  • Standard dentistry: consultations, fillings, extractions, i set of plastic dentures and prevention are covered according to protocols
  • Specialised dentistry: root canals and periodontal treatment, limited to R2,500 per family
Overall Annual Limit (OAL):
PMBs only, in private hospitals
Contributions:
Main: Adult: Child:
Total Cost: R1,832 R1,537 R594
Children: Pay for all children
Income limit: R12,251-R16,250 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Orthodontics:
Maxillo Facial Surgery:

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MEDICATION:
Chronic:
Overall Annual Limit (OAL):
PMBs only, in private hospitals
Contributions:
Main: Adult: Child:
Total Cost: R1,832 R1,537 R594
Children: Pay for all children
Income limit: R12,251-R16,250 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Acute (presrcibed) medication:
Over-the-counter:
Birth Control:
On Discharge:
Notes:

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OPTOMETRY:
Optometry:
  • R1,850 per person every two years
Overall Annual Limit (OAL):
PMBs only, in private hospitals
Contributions:
Main: Adult: Child:
Total Cost: R1,832 R1,537 R594
Children: Pay for all children
Income limit: R12,251-R16,250 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
Overall Annual Limit (OAL):
PMBs only, in private hospitals
Contributions:
Main: Adult: Child:
Total Cost: R1,832 R1,537 R594
Children: Pay for all children
Income limit: R12,251-R16,250 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:


Out-of-hospital:
  • Psychologist: 8 consults per family

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OTHER BENEFITS:
General Appliances:
Overall Annual Limit (OAL):
PMBs only, in private hospitals
Contributions:
Main: Adult: Child:
Total Cost: R1,832 R1,537 R594
Children: Pay for all children
Income limit: R12,251-R16,250 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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1.1. Hearing Aids:
  • R2,400 per person every 4 years
1.2. Wheelchairs:
Dialysis:
HIV:
Emergency Transport:
International Coverage:
Other:

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WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
Overall Annual Limit (OAL):
PMBs only, in private hospitals
Contributions:
Main: Adult: Child:
Total Cost: R1,832 R1,537 R594
Children: Pay for all children
Income limit: R12,251-R16,250 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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

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PROSTHESIS:
Overal Limit:
Overall Annual Limit (OAL):
PMBs only, in private hospitals
Contributions:
Main: Adult: Child:
Total Cost: R1,832 R1,537 R594
Children: Pay for all children
Income limit: R12,251-R16,250 (other limits)
Day-to-Day Benefit:
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