CUSTOM OPTION
Targeted at young and healthy members. The Custom plan provides you and your dependants an opportunity to make health part of your journey with quality provider networks and a continuously enhanced benefit package.
MONTHLY CONTRIBUTION
| SALARY BAND | MEMBER | ADULT | CHILD |
|---|---|---|---|
| R0 – R3 855 | R1 324 | R1 060 | R339 |
| R3 856 – R6 950 | R1 393 | R1 109 | R352 |
| R6 951 – R10 157 | R1 525 | R1 224 | R382 |
| R10 158 – R12 547 | R1 743 | R1 399 | R445 |
| R12 548 – R16 955 | R2 428 | R1 945 | R609 |
| R16 956 + | R2 671 | R2 139 | R669 |
DESIGNATED SERVICE PROVIDERS (DSPs)
MHC’s philosophy is to provide quality, comprehensive healthcare while maintaining affordable contributions. In order to strike the necessary balance to achieve our philosophy, it is necessary to introduce DSPs. In this way, MHC can contain spiralling healthcare costs but nevertheless ensure that members receive the most appropriate treatment.
Find GP’s, Dentists and Pharmacies on CareCross lookup tool
View the list of Network Hospitals
Click here to look up your Medication Formulary
View the Chronic Conditions covered by the Custom Option
OUT-OF-HOSPITAL BENEFITS
Not sure what we mean? Refer to glossary on page 73 of the Member Guide.
| PRIMARY CARE NETWORK ONLY | |
|---|---|
| General practitioners (GPs) | Unlimited at the primary care network service provider |
| Specialists | M = R4 775 M+ = R9 560 Subject to network GP referral, pre-authorisation and managed care/Scheme protocols |
| Medicines | |
| Acute | Unlimited at the primary care network provider – subject to network formulary |
| Over the counter (OTC) | Single member = 5 prescriptions Family = 7 prescriptions |
| Chronic | 23 CDL conditions (see page 20) and 2 non-CDL formulary available on website Subject to use of primary network provider and protocols |
| Optometry Optical benefit available per beneficiary every 24 months |
1 optical test per beneficiary per year 1 pair of clear, standard mono- or bifocal lenses in a standard frame OR Contact lenses to the value of R647 R247 towards a frame outside the standard range Subject to use of primary care network service provider and protocols |
| Pathology and Radiology Out of hospital |
Pathology and radiology - subject to network GP referral and formulary tests |
| Dentistry Basic - per beneficiary per annum Subject to use of primary network provider and protocols |
• One dental examination Per adult beneficiary – 1 set of plastic dentures every 24 months |
| MRI, CT, PET and radio isotope scans | Sub-limit per beneficiary = R3 665, subject to specialist limit |
| External prostheses |
R12 250 per family per annum. Subject to clinical protocols and the overall annual limit |
| Medical and surgical appliances (in- and out-of-hospital) | The following appliances are subject to the annual limit of R8 565 per family Subject to motivation and pre-authorisation Please call 0861 000 300 for assistance |
| Glucometers | R915 per beneficiary every 2 years |
| Nebulisers | R915 per family every 3 years |
| Other Appliances – once every 4 years | Subject to clinical protocols. Please note hearing aids are not covered on the Custom option |
| ADDITIONAL BENEFITS | |
|---|---|
|
Free Hello Doctor consults |
Telephonic advice via HELLO DOCTOR. Talk or text a doctor on your phone, anytime, anywhere, any official language – for free. Refer to page 10 for detailed information |
| Out-of-area or emergency visits | Per family = 3 visits to a maximum of R1 105. Approved trauma events not requiring hospitalisation are payable from the overall annual limit. Clinical protocols and policies applicable. |
|
Wellness Benefit |
Refer to page 5 and 9 for the detailed benefits on free early detection, preventative care, ante-natal care and patient care programmes. |
This option is exempt from PMBs. Terms and conditions apply including specific exclusions
IN-HOSPITAL BENEFITS
| IMPORTANT: Treatment performed in-hospital needs to be pre-authorised prior to commencement of treatment. Some conditions will require you to register onto the Patient Care Programme to access benefits. MHC will pay benefits in accordance with the Scheme Rules and clinical protocols per condition. The sub-limits specified below apply per year. If you join the Scheme after January your limits will be pro-rated. | |
| Overall Annual Limit (OAL) |
Single member = R382 420 |
| Public hospital | Unlimited treatment in accordance with Scheme and state protocols |
| Private hospital | Subject to the overall annual limit and use of the Scheme network hospitals |
| Network hospital: Life Healthcare | A 30% co-payment will be applied for voluntary use of a non-network provider |
| CO-PAYMENT FOR SPECIALISED PROCEDURES/TREATMENT | |
| Procedure/treatment Gastroscopy, colonoscopy, sigmoidoscopy, functional nasal and sinus procedures, nail surgery, treatment of headaches, removal of skin lesions |
If performed in hospital A co-payment of R1 200 will apply per admission which needs to be paid directly by the member to the treating practitioner If performed out of hospital Procedure will be paid at scheme rate subject to pre-authorisation and clinical protocols |
| GPs and specialists | Unlimited treatment in accordance with Scheme protocols and use of Network Providers Admission to private hospital subject to overall annual limit Claims paid up to the agreed rate with the provider |
| To-take-out medicine | Up to 7 days |
| Internal Prostheses |
Per family per annum = R19 610 where approved during hospital admission subject to the overall annual limit |
| Alternate care instead of hospitalisation |
Per family = 30 days to a maximum of R25 740 |
| Mental health (in and out of hospital) |
Subject to the overall annual limit and up to a sub-limit of R27 270 Subject to clinical protocols and pre-authorisation |
| Alcohol and drug rehabilitation | 100% of the negotiated rate, at a South African National Council on Alcoholism and Drug Dependence (SANCA)-approved facility, subject to the mental health sub-limit |
| Oncology |
Per family = R85 800, subject to overall annual limit |
| Pathology |
Per beneficiary = R8 980, subject to overall annual limit |
| Radiology |
Per beneficiary = R8 980, subject to overall annual limit |
| Medical and surgical appliances (in and out of hospital) |
Per family = R8 565, subject to overall annual limit |
| Sub-limits to appliance benefit |
Glucometer (per beneficiary every 2 years) - R915 Nebuliser (per family every 3 years) - R915 |
| Maternity |
Confinement: Private hospital – Subject to overall annual limit and use of the hospital network providers |
| Ambulance | Emergency road transport only. Subject to use of DSP, clinical protocols and preauthorization |
This option is exempt from PMBs. Terms and conditions apply including specific exclusions.
EXCLUSIONS
- General exclusions as set out in the Annexure D of the Rules
- Dental exclusions as set out in Annexure F of the Rules
- Admission for diagnostic investigations
- Arthroscopy
- Brachytherapy for prostate cancer
- Bunionectomy
- Chronic renal dialysis
- Cochlear Implants
- Corneal transplants
- Dentistry in hospital
- Elective Caesarean sections
- Infertility
- Joint replacement
- Kidney dialysis
- Orthopaedic procedures
- Osseo integrated implants
- Refractive eye surgery
- Removal of varicose veins
- Skin disorders