Medimed Alpha medial aid plan: 2017

Out-of-hospital, scheme pays for some: out-of-hospital claims but with a 25% or 40% co-payment from member. All else paid from out of pocket, unless PMB. Pay for all children.

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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: R1,020 R1,020 R400
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: out-of-hospital claims but with a 25% or 40% co-payment from member. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Hospital Choice:
  • Unlimited
Specialised Radiology:
  • 25% co-payment for non-PMBs
    • , in and out of hospital
Supplementary Services: (Physio, etc)
  • 40% co-payment for non-PMBs
  • R4,500 per family, for in and out-of-hospital
Transplants:
  • R100,000 per family
  • Benefit is shared with Dialysis Benefit
Co-payments:
  • Member pays 25% or 40% co-payment to providers for in-hospital treatment of non-PMBs conditions. No co-payment for PMBs.
Alternatives to hospitals:
  • R5,000 per family

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • R3,300 per person and R7,900 per family with 25% co-payment
  • Shared with specialist benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,020 R1,020 R400
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: out-of-hospital claims but with a 25% or 40% co-payment from member. 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:
  • 25% co-payment for non-PMBs
General radiology:
  • 25% co-payment for non-PMBs
Specialised radiology:
  • 25% co-payment for non-PMBs
Supplementary Services: (Physio, etc)
  • 40% co-payment for non-PMBs
  • R4,500 per family, for in and out-of-hospital

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MATERNITY BENEFITS:
Hospital stay:
  • 25% co-payment for doctors bill
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,020 R1,020 R400
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: out-of-hospital claims but with a 25% or 40% co-payment from member. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Consultations:
  • 2 prenatal consults, paid by scheme
  • 1 paediatric consult, paid by scheme
Scans:
  • 2 x 2D scans, paid by scheme

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • R200,000 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: R1,020 R1,020 R400
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: out-of-hospital claims but with a 25% or 40% co-payment from member. 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: Unlimited, with a 40% co-payment
  • Specialised dentistry: R4,500 per person and R9,000 per family, with a 40% co-payment
  • In-hospital (wisdom teeth and children under 12): R12,000 per family with a 25% co-payment for doctors and 40% co-payment for related costs
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,020 R1,020 R400
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: out-of-hospital claims but with a 25% or 40% co-payment from member. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Orthodontics: See above
Maxillo Facial Surgery:

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MEDICATION:
Chronic:
  • PMB chronic: paid by scheme on authorisation
  • Extended chronic conditions: R3,000 per person and R6,000 per family, paid at 75% scheme rate
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,020 R1,020 R400
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: out-of-hospital claims but with a 25% or 40% co-payment from member. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Acute (presrcibed) medication:
  • R3,300 per person, R7,900 per family
  • 60% scheme rate, member pays balance
Over-the-counter:
  • R120 per prescription and R1,200 per family, subject to acute medicine limit (see above) and a 40% co-payment
Birth Control:
On Discharge:
Notes:

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OPTOMETRY:
Optometry:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,020 R1,020 R400
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: out-of-hospital claims but with a 25% or 40% co-payment from member. 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:
  • R6,500 per family, paid at 100% scheme rate. Thereafter paid at 75% scheme rate up to a limit of R12,000 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,020 R1,020 R400
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: out-of-hospital claims but with a 25% or 40% co-payment from member. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:


Out-of-hospital:
  • R3,300 per person and R7,900 per family with 25% co-payment
  • Shared with GPs and specialist benefit

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OTHER BENEFITS:
General Appliances:
  • R4,000 per family
  • Nebulisers and glucometers: R500
  • 60% scheme rate, member pays balance
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,020 R1,020 R400
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: out-of-hospital claims but with a 25% or 40% co-payment from member. 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:
  • See "General Appliances" limit
1.2. Wheelchairs:
  • See "General Appliances" limit
Dialysis:
  • R100,000 per family
  • Benefit is shared with Organ Transplant Benefit
HIV:
  • Unlimited, subject to protocols
Emergency Transport: ER 24
International Coverage:
Other:

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WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
  • Covered up to R1,200 per person and R2,400 per family for all preventative care benefits
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,020 R1,020 R400
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: out-of-hospital claims but with a 25% or 40% co-payment from member. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Pneumonia vaccines:
Back Rehabilitation Programme:
Biometric Screening:
  • Covered up to R1,200 per person and R2,400 per family for all preventative care benefits
Child Immunisation:
Pap Smear:
  • Covered up to R1,200 per person and R2,400 per family for all preventative care benefits
Mammogram:
  • Covered up to R1,200 per person and R2,400 per family for all preventative care benefits
PAS Test:
  • Covered up to R1,200 per person and R2,400 per family for all preventative care benefits
HIV Test:
  • Covered up to R1,200 per person and R2,400 per family for all preventative care benefits

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PROSTHESIS:
Overal Limit:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,020 R1,020 R400
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: out-of-hospital claims but with a 25% or 40% co-payment from member. 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