Medihelp Dimension Prime 3 Network medical aid plan: 2017

Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, GPs, specialists, supplementary health and medication, dentistry, optometry, medical appliances. Limits apply. All else paid 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: R2,184 R1,848 R636
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, GPs, specialists, supplementary health and medication, dentistry, optometry, medical appliances. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Hospital Choice:
  • Network (106 facilities)
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: R7,850 co-payment
  • In-hospital dentistry for children younger than 5yrs: R780 co-payment
  • Gastroscopy and Colonoscopy in doctor's rooms: no co-payment
  • Gastroscopy, Colonoscopy, Arthroscopy, Sigmoidoscopy in-hospital: R2,800 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:
  • Shared with: GPs, specialists, psychology, physiotherapy, supplementary health services, acute medicine and over the counter
Main M1 M2 M3+
R5,700 R9,550 R11,700 R12,600
  • 2 consultations for babies under 1yr old, paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,184 R1,848 R636
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, GPs, specialists, supplementary health and medication, dentistry, optometry, medical appliances. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Specialists consultations:
  • See GP benefit, above
Pathology:
  • M =R2,450 and M+ =R3,450
  • Shared with basic radiology
General radiology:
  • M =R2,450 and M+ =R3,450
  • Shared with pathology benefit
Specialised radiology:
  • Paid by scheme, with a R1,500 co-payment, in or out of hospital
Supplementary Services: (Physio, etc)
  • See GP benefit, above
  • 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: R2,184 R1,848 R636
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, GPs, specialists, supplementary health and medication, dentistry, optometry, medical appliances. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Consultations:
  • 12 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: R2,184 R1,848 R636
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, GPs, specialists, supplementary health and medication, dentistry, optometry, medical appliances. Limits apply. All else paid from 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: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,184 R1,848 R636
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, GPs, specialists, supplementary health and medication, dentistry, optometry, medical appliances. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Orthodontics:
  • R8,230 per person per lifetime, 9-18 yrs only
Maxillo Facial Surgery:

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MEDICATION:
Chronic:
  • PMB chronic: paid by scheme
>
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,184 R1,848 R636
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, GPs, specialists, supplementary health and medication, dentistry, optometry, medical appliances. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Acute (presrcibed) medication:
  • Shared with the GP, specialists, mental health, supplementary services
Main M1 M2 M3+
R5,700 R9,550 R11,700 R12,600
Over-the-counter:
  • See "Acute medicine" benefit
Birth Control:
  • See "Acute Medicine" benefit, above
On Discharge:
  • R320 per admission
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: R600 every 2 years
  • Lenses: Every 2 years
  • Contacts: R1,000 per person every 2 years
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,184 R1,848 R636
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, GPs, specialists, supplementary health and medication, dentistry, optometry, medical appliances. Limits apply. All else paid from 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:
  • R25,150 per person and R33,700 per family
  • Includes in and out of hospital treatment
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,184 R1,848 R636
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, GPs, specialists, supplementary health and medication, dentistry, optometry, medical appliances. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:


Out-of-hospital: ul>
  • Shared with: GPs, Specialists, Psychology, physiotherapy, supplementary health services, acute medicine and over the counter medicine
  • paid by scheme
    • Main M1 M2 M3+
    R5,700 R9,550 R11,700 R12,600

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    OTHER BENEFITS:
    General Appliances:
    • Medical Appliances, hyperbaric oxygen: No benefit
    • Stoma products and urine bags: paid by scheme
    • CPAP apparatus: R8,400 per person every two years
    Overall Annual Limit (OAL):
    Unlimited overall, with sub-limits
    Contributions:
    Main: Adult: Child:
    Total Cost: R2,184 R1,848 R636
    Children: Pay for maximum 2 children under 18yrs.
    Day-to-Day Benefit:
    Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, GPs, specialists, supplementary health and medication, dentistry, optometry, medical appliances. Limits apply. All else paid from out of pocket, unless PMB.
    Main: Adult: Child:
    (S) Savings: R0- R0- R0-

    Compare with these plans:

    1.1. Hearing Aids:
    • R4,080 per family every 3 years
    1.2. Wheelchairs:
    • R4,080 per family every 3 years
    Dialysis:
    • Unlimited
    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: R2,184 R1,848 R636
    Children: Pay for maximum 2 children under 18yrs.
    Day-to-Day Benefit:
    Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, GPs, specialists, supplementary health and medication, dentistry, optometry, medical appliances. Limits apply. All else paid from out of pocket, unless PMB.
    Main: Adult: Child:
    (S) Savings: R0- R0- R0-

    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: R2,184 R1,848 R636
    Children: Pay for maximum 2 children under 18yrs.
    Day-to-Day Benefit:
    Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, GPs, specialists, supplementary health and medication, dentistry, optometry, medical appliances. Limits apply. All else paid from 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