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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 300R1 055R845R270
R3 301 – R5 950R1 110R885R280
R5 951 – R8 700R1 215R975R305
R8 701 – R10 750R1 390R1 115R355
R10 751 +R1 935R1 550R485

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 pg 58 of 2021 Member Guide.

PRIMARY CARE NETWORK ONLY
General practitioners (GPs) Unlimited at the primary care network service provider
Specialists M = R3 900
M+ = R7 800
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 24 CDL conditions (see page 35) and 2 non CDL. Subject to use of primary network provider and 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 R525
R200 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
Per beneficiary per annum:
• one dental examination
• scaling
• eight primary extractions
• eight fillings
• polishingPer adult beneficiary – 1 set of plastic dentures every 24 month
MRI, CT, PET and radio isotope scans Sub-limit per beneficiary = R3 000, 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
Subject to motivation and pre-authorization
Please call 0861 000 300 for assistance
Glucometers R790 per beneficiary every 2 years
Nebulisers R790 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 consults via HELLO DOCTOR. Talk or text a doctor on your phone, anytime, anywhere, any official language – for free. Refer to page 8 for detailed information

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

Wellness Benefit

Refer to page 7 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 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 = R16 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. 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