Medshield MediPlus medical aid plan: 2017

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

View all plans in this scheme

IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,544 R1,797 R558
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, some non-surgical procedures including scopes,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: RM=R6,750
M1 =R9,420
M2 =R10,600
M3 = R11,910
M4+ +R13,050		 R R

Compare with these plans:
Hospital Choice:
  • Network
Specialised Radiology:
  • R10,200 per family, with 10% co-payment in and out of hospital
Supplementary Services: (Physio, etc)
  • Physiotherapy: Unlimited
Transplants:
  • R140,000 per family
Co-payments:
  • non-PMBs internal prostheses and devices: 25% co-payment
  • non-PMBs PET and PET-CT scan: 10% co-payment
Alternatives to hospitals:
  • Physical rehabilitation, sub-acute facilities, nursing services, hospice: R47,000 per family

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Paid from day-to-day benefit
  • 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):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,544 R1,797 R558
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, some non-surgical procedures including scopes,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: RM=R6,750
M1 =R9,420
M2 =R10,600
M3 = R11,910
M4+ +R13,050		 R R

Compare with these plans:

Specialists consultations:
  • One consultation per family, then from day-to-day benefit
  • 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
Pathology:
  • Paid from day-to-day benefit
General radiology:
  • Paid from day-to-day benefit
Specialised radiology:
  • R10,200 per family, with 10% co-payment for non-PMBs
  • In and out of hospital
Supplementary Services: (Physio, etc)
  • Paid from day-to-day benefit

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MATERNITY BENEFITS:
Hospital stay:
  • 200% scheme tariff for midwife
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,544 R1,797 R558
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, some non-surgical procedures including scopes,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: RM=R6,750
M1 =R9,420
M2 =R10,600
M3 = R11,910
M4+ +R13,050		 R R

Compare with these plans:

Consultations:
  • 12 consults
  • Antenatal classes: R500 per family
  • 4 post-natal consultations with midwife
  • Paid by scheme
Scans:
  • 2x 2D scans
  • 1x Amniocentesis
  • Paid by scheme

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • R230,000 per family
  • Biological medicine: 15% co-payment, subject to above limit and limited to R100,000
  • 6 visits per family from social worker, for psychological support during treatment
  • Macular degeneration: R40,000 per family
  • Breast reconstruction: R80,000 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: R2,544 R1,797 R558
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, some non-surgical procedures including scopes,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: RM=R6,750
M1 =R9,420
M2 =R10,600
M3 = R11,910
M4+ +R13,050		 R R

Compare with these plans:

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DENTISTRY:
Dentistry:
  • Standard dentistry:unlimited, including in-hospital for under 6yr olds
  • Specialised dentistry: R10,000 per family for wisdom teeth, implants, orthodontic treatment, crowns, bridges, inlays, periodontics etc. Paid by scheme.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,544 R1,797 R558
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, some non-surgical procedures including scopes,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: RM=R6,750
M1 =R9,420
M2 =R10,600
M3 = R11,910
M4+ +R13,050		 R R

Compare with these plans:

Orthodontics:
  • Paid from specialised dentistry benefit
Maxillo Facial Surgery:
  • R12,985 per family

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MEDICATION:
Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs: Additional 14 conditions covered
  • R5,385 per person and R10,775 per family, thereafter unlimited for PMBs
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,544 R1,797 R558
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, some non-surgical procedures including scopes,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: RM=R6,750
M1 =R9,420
M2 =R10,600
M3 = R11,910
M4+ +R13,050		 R R

Compare with these plans:
Acute (presrcibed) medication:
  • Paid from day-to-day benefit
Over-the-counter:
  • R535 per person and R985 per family limited to R185 per script. From day-to-day benefit
Birth Control:
  • R140 per monthly script
  • Mirena: one per female every four years. Includes consultation, insertion if done in rooms.
On Discharge:
  • R500 per admission
Notes:
  • PMB: Restrictive 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:
  • R1,765 per person, every 2 years
  • Refractive surgery: R7,500 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,544 R1,797 R558
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, some non-surgical procedures including scopes,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: RM=R6,750
M1 =R9,420
M2 =R10,600
M3 = R11,910
M4+ +R13,050		 R R

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
  • R26,000 per family, in and out-of-hospital
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,544 R1,797 R558
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, some non-surgical procedures including scopes,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: RM=R6,750
M1 =R9,420
M2 =R10,600
M3 = R11,910
M4+ +R13,050		 R R

Compare with these plans:


Out-of-hospital:
  • See above limit

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OTHER BENEFITS:
General Appliances:
  • Overall limit: R7,490 per family
  • Peak flow meters, nebulizers, glucometers and blood pressure monitors: R750 per person, subject to above limit
  • Stoma products: Unlimited
  • Oxygen therapy equipment: Unlimited
  • Ventilators: Unlimited
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,544 R1,797 R558
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, some non-surgical procedures including scopes,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: RM=R6,750
M1 =R9,420
M2 =R10,600
M3 = R11,910
M4+ +R13,050		 R R

Compare with these plans:

1.1. Hearing Aids:
  • See "General Appliances" limit
1.2. Wheelchairs:
  • See "General Appliances" limit
Dialysis:
  • R175,000 per family
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):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,544 R1,797 R558
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, some non-surgical procedures including scopes,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: RM=R6,750
M1 =R9,420
M2 =R10,600
M3 = R11,910
M4+ +R13,050		 R R

Compare with these plans:

Pneumonia vaccines:
  • Covered
    • 60yrs+
Back Rehabilitation Programme:
Biometric Screening:
  • Covered
Child Immunisation:
  • Covered
Pap Smear:
  • Covered
Mammogram:
  • Covered for 40yrs+, every 2 years.
PAS Test:
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: R2,544 R1,797 R558
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, some non-surgical procedures including scopes,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: RM=R6,750
M1 =R9,420
M2 =R10,600
M3 = R11,910
M4+ +R13,050		 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