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CUSTOM OPTION

Targeted at young and healthy members, this plan is a network option that has an overall annual hospital limit and sub-limits for associated providers. Access to unlimited day to day benefits. Cover for comprehensive pre- and post-natal health services for maternity and early childhood. 25 chronic conditions are covered subject to use of our formulary and designated service provider. This option includes separate cover for Over the Counter medicines (OTC).

MONTHLY CONTRIBUTION


SALARY BANDMEMBERADULTCHILD
R0 – R3 200R1 010R810R225
R3 201 – R5 800R1 060R845R265
R5 801 – R8 500R1 160R930R290
R8 501 – R10 500R1 330R1 065R335
R10 501 +R1 845R1 480R460

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.

Members may choose not to use the DSP but will be liable for any co-payment over and above what is charged by the DSP.

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 pg 63 of 2020 Member Guide.

PRIMARY CARE NETWORK ONLY
General practitioners (GPs) Unlimited at the primary care network service provider
Specialists M = R3 800
M+ = R7 500
Subject to network GP referral, pre-authorisation and managed care/Scheme protocols
Medicines
Acute Unlimited at the primary care network service provider - subject to network formulary
Over the counter (OTC) Single member = 5 prescriptions
Family = 7 prescriptions
Chronic 25 conditions (see page 12 of benefit guide)
Subject to primary network service provider protocols
No benefit if a non-network provider is used
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 R505
R195 towards a frame outside the standard range

Subject to use of primary care network service provider and protocols

Dentistry
Basic - per beneficiary per annum
Per beneficiary per annum:
• one dental examination
• scaling
• eight primary extractions
• eight fillings
• polishing
Specialised Per adult beneficiary – 1 set of acrylic dentures every 24 months
MRI, CT, PET and radio isotope scans Sub-limit per beneficiary = R2 700, subject to specialist limit
External prostheses

R10 000 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 R7 000 per family
Glucometers R790 per beneficiary every 2 years
Nebulisers R790 per family every 3 years
Other Appliances – once every 4 years Subject to clinical protocols
ADDITIONAL BENEFITS

Free Hello Doctor consults

Telephonic consults via HELLO DOCTOR. Talk or text a doctor on your phone, anytime,

anywhere, in any language – for free

Refer to page 6 for detailed information

Out-of-area or emergency visits Per family = 3 visits to a maximum of R1 000

Wellness Benefit

Refer to page 9 of the 2020 Member Guide for the detailed benefits on free early detection, preventative care,

ante-natal care and patient care programmes.

IN-HOSPITAL BENEFITS

 

IMPORTANT: Treatment performed in-hospital or falls within the Major Medical Benefits needs to be pre-authorised prior to commencement of treatment. Conditions such as cancer 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 = R312 000
Family = R548 000
All services are subject to pre-authorisation and managed care protocols

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 practioner
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 = R15 000 where approved during hospital admission subject to the overall annual limit

Alternate care instead of hospitalisation

Per family = 30 days to a maximum of R21 000

Mental health (in and out of hospital)

Subject to the overall annual limit and up to a sub-limit of R22 250

Subject to clinical protocols

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 = R70 000, subject to overall annual limit

Pathology

Per beneficiary = R7 330, subject to overall annual limit

Radiology

Per beneficiary = R7 330, subject to overall annual limit

Medical and surgical appliances
(in and out of hospital)

Per family = R7 000, subject to overall annual limit

Maternity

Confinement:
Public hospital – Treatment in accordance with Scheme protocols

Private hospital – Subject to overall annual limit and use of the hospital network providers

Ambulance Emergency road transport only

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