Medihelp Dimension Prime 2 medical aid plan: 2017

Out-of-hospital, scheme pays for some: specialised radiology (co-payment), GPs, optometry, dentistry, maternity, infant paediatrics, medical appliances. Limits apply. Limits apply. All else paid from savings or from out of pocket, unless PMB. Pay for maximum 2 children under 18yrs. .

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IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,136 R1,746 R642
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), GPs, optometry, dentistry, maternity, infant paediatrics, medical appliances. Limits apply. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,096 R2,520 R936

Compare with these plans:
Hospital Choice:
  • Unlimited
Specialised Radiology:
  • Co-payment of R1,500, in or out of hospital
Supplementary Services: (Physio, etc)
  • 100% scheme rate
  • In addition, scheme covers professional services for up to 30 days after discharge following hospital admission, including speech therapy, occupational therapy and physiotherapy. M =R1,650 and M+ =R2,200
Transplants:
  • Cornea implants: R24,750 per implant
  • Otherwise, unlimited
Co-payments:
  • Back and neck fusion: R9,000 co-payment
  • In-hospital dentistry for children younger than 5yrs: R1,810 co-payment, with dentist's account paid out of savings account
  • Gastroscopy and Colonoscopy in doctor's rooms: no co-payment
  • Gastroscopy, Colonoscopy, Arthroscopy, Sigmoidoscopy in-hospital: R3,400 co-payment
  • Specialised radiology: R1,500 co-payment
Alternatives to hospitals:
  • Hospice and sub-acute facilities: paid by scheme, subject to authorisation
  • Private nursing: paid by scheme, subject to authorisation

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • GP consults: M =2 consults and M+ =4 consults, paid by scheme
  • 2 consults for babies under 1yr old, paid by scheme
  • Otherwise, paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,136 R1,746 R642
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), GPs, optometry, dentistry, maternity, infant paediatrics, medical appliances. Limits apply. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,096 R2,520 R936

Compare with these plans:

Specialists consultations:
  • Paid from day-to-day benefit
Pathology:
  • Paid from day-to-day benefit
General radiology:
  • Paid from day-to-day benefit
Specialised radiology:
  • Paid by scheme, with a R1,500 co-payment, in or out of hospital
Supplementary Services: (Physio, etc)
  • Paid from day-to-day benefit
  • Also, speech therapy, occupational therapy and physiotherapy for up to 30 days after discharge following hospital admission. Limited to R1,650 per person and R2,200 per family

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MATERNITY BENEFITS:
Hospital stay:
    Hospital delivery:
  • 100% scheme rate
  • Home delivery: R11,350
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,136 R1,746 R642
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), GPs, optometry, dentistry, maternity, infant paediatrics, medical appliances. Limits apply. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,096 R2,520 R936

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Consultations:
  • 6 consults, paid by scheme
  • 2 paediatric consults, paid by scheme
Scans:
  • 2 x 2D scans, paid by scheme

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • 100% of cost, in and out-of-hospital, subject to treatment approval
  • Designated Service Provider: ICON

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: R2,136 R1,746 R642
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), GPs, optometry, dentistry, maternity, infant paediatrics, medical appliances. Limits apply. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,096 R2,520 R936

Compare with these plans:

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DENTISTRY:
Dentistry:
  • 2 emergency visits per year, paid by scheme
  • Otherwise, paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,136 R1,746 R642
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), GPs, optometry, dentistry, maternity, infant paediatrics, medical appliances. Limits apply. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,096 R2,520 R936

Compare with these plans:

Orthodontics:
  • Paid from day-to-day benefit, 9-18 yrs only
Maxillo Facial Surgery:
  • Paid from day-to-day benefit

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MEDICATION:
Chronic:
  • PMB chronic: paid by scheme
  • non-PMBs: paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,136 R1,746 R642
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), GPs, optometry, dentistry, maternity, infant paediatrics, medical appliances. Limits apply. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,096 R2,520 R936

Compare with these plans:
Acute (presrcibed) medication:
Over-the-counter:
  • M= R1,000 and M+= R2,000
  • Shared with GP and Acute medicine benefit
  • paid by scheme
Birth Control:
  • See "Acute Medicine" benefit, above
On Discharge:
  • Paid from day-to-day benefit
Notes:
  • PMBs chronic: only 40% of the reference price is paid if medicine is outside the formulary and/or obtained from non-network provider
  • For acute and non-PMBs chronic medicines:
    • 80% of scheme rate where no generic is available
    • 70% of MMAP (maximum medical aid price) for voluntary use of original medicine where generic is available

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OPTOMETRY:
Optometry:
  • Eye test: one every 2 years
  • Frames: R200 every 2 years
  • Lenses: Every 2 years
  • Contacts: R950 per person every 2 years
  • paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,136 R1,746 R642
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), GPs, optometry, dentistry, maternity, infant paediatrics, medical appliances. Limits apply. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,096 R2,520 R936

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
  • R21,000 per person and R28,750 per family
  • Includes in and out of hospital treatment
  • paid by scheme, subject to approval
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,136 R1,746 R642
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), GPs, optometry, dentistry, maternity, infant paediatrics, medical appliances. Limits apply. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,096 R2,520 R936

Compare with these plans:


Out-of-hospital:
  • Psychiatry: See above
  • Psychology: paid from day-to-day benefit

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OTHER BENEFITS:
General Appliances:
  • Medical Appliances and CPAP apparatus: paid from day-to-day savings
  • Hyperbaric oxygen: R550 per family
  • Stoma products and urine bags: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,136 R1,746 R642
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), GPs, optometry, dentistry, maternity, infant paediatrics, medical appliances. Limits apply. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,096 R2,520 R936

Compare with these plans:

1.1. Hearing Aids:
  • Paid from day-to-day benefit
1.2. Wheelchairs:
  • Paid from day-to-day benefit
Dialysis:
  • Unlimited
  • Paid by scheme
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
Emergency Transport:
  • Netcare 911
International Coverage:
Other:
  • Oxygen out-of-hospital: Unlimited, at 100% scheme rate

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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: R2,136 R1,746 R642
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), GPs, optometry, dentistry, maternity, infant paediatrics, medical appliances. Limits apply. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,096 R2,520 R936

Compare with these plans:

Pneumonia vaccines:
  • Covered, 55yrs+
Back Rehabilitation Programme:
  • Covered
Biometric Screening:
  • Covered
Child Immunisation:
  • Covered
Pap Smear:
  • Covered
Mammogram:
  • Covered, 40yrs+
PAS Test:
  • Covered, 40yrs+
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: R2,136 R1,746 R642
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), GPs, optometry, dentistry, maternity, infant paediatrics, medical appliances. Limits apply. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,096 R2,520 R936

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