Medshield MediValue 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: R1,521 R1,323 R414
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= R4,815
M1= R5,240
M2= R5,900
M3= R6,660
M4+ =R7,600		 R R

Compare with these plans:
Hospital Choice:
  • Network
Specialised Radiology:
  • R5,560 per family, with 8% co-payment in and out of hospital
Supplementary Services: (Physio, etc)
  • Physiotherapy: Unlimited
Transplants:
Co-payments:
Alternatives to hospitals:
  • Physical rehabilitation, sub-acute facilities, nursing services, hospice: R23,000 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: R1,521 R1,323 R414
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= R4,815
M1= R5,240
M2= R5,900
M3= R6,660
M4+ =R7,600		 R R

Compare with these plans:

Specialists consultations:
  • Three consultations 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:
  • Bone densitometry scan: one per person
  • Otherwise, from day-to-day benefit
Specialised radiology:
  • R5,560 per family, with 8% 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: R1,521 R1,323 R414
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= R4,815
M1= R5,240
M2= R5,900
M3= R6,660
M4+ =R7,600		 R R

Compare with these plans:

Consultations:
  • 6 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):
  • PMBs only
  • 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: R1,521 R1,323 R414
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= R4,815
M1= R5,240
M2= R5,900
M3= R6,660
M4+ =R7,600		 R R

Compare with these plans:

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DENTISTRY:
Dentistry:
  • Standard dentistry: R1,360 per family paid by scheme, then from day-to-day benefit. Includes in-hospital for under 6yr olds
  • Specialised dentistry: R5,000 per family for wisdom teeth, implants and orthodontic treatment, paid by scheme
  • Crowns, bridges, inlays, dentures, periodontics, models: from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,521 R1,323 R414
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= R4,815
M1= R5,240
M2= R5,900
M3= R6,660
M4+ =R7,600		 R R

Compare with these plans:

Orthodontics: See above
Maxillo Facial Surgery:
  • R6,095 per family

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MEDICATION:
Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,521 R1,323 R414
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= R4,815
M1= R5,240
M2= R5,900
M3= R6,660
M4+ =R7,600		 R R

Compare with these plans:
Acute (presrcibed) medication:
  • Paid from day-to-day benefit
Over-the-counter:
  • R185 per script. Limited to R400 per person and R600 per family. Paid 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:
  • R400 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:
  • R1,550 per person, every 2 years
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,521 R1,323 R414
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= R4,815
M1= R5,240
M2= R5,900
M3= R6,660
M4+ =R7,600		 R R

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,521 R1,323 R414
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= R4,815
M1= R5,240
M2= R5,900
M3= R6,660
M4+ =R7,600		 R R

Compare with these plans:


Out-of-hospital:
  • Paid from day-to-day benefit

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OTHER BENEFITS:
General Appliances:
  • Overall limit: R2,140 per family, in and out of hospital
  • Peak flow meters, nebulizers, glucometers and blood pressure monitors: R750 per person, subject to above limit
  • Stoma products: Unlimited
  • Oxygen therapy equipment: unlimited, PMBs only
  • Ventilators: unlimited, PMBs only
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,521 R1,323 R414
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= R4,815
M1= R5,240
M2= R5,900
M3= R6,660
M4+ =R7,600		 R R

Compare with these plans:

1.1. Hearing Aids:
  • See "General Appliances" limit
1.2. Wheelchairs:
  • See "General Appliances" limit
Dialysis:
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: R1,521 R1,323 R414
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= R4,815
M1= R5,240
M2= R5,900
M3= R6,660
M4+ =R7,600		 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: R1,521 R1,323 R414
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= R4,815
M1= R5,240
M2= R5,900
M3= R6,660
M4+ =R7,600		 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