This entry level option is ideal for first time medical cover buyers – young and healthy individuals. It offers them peace of mind every stage of their health journey by using quality provider networks that offer simple day-to-day benefits and hospital cover. Here’s a high-level summary of benefits offered on the Essential option:
|R0 – R3 100||R385||R230||R155|
|R3 101 – R6 650||R410||R245||R155|
|R6 651 – R9 750||R585||R355||R230|
|R9 751 +||R675||R410||R275|
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.
|PRIMARY CARE NETWORK ONLY|
|General practitioners (GPs)||Unlimited at the primary care network service provider|
|Specialist Limit||M = R1 500
M+ = R3 000
Subject to network GP referral, pre-authorisation and managed care/Scheme protocols
|Antenatal care||Antenatal care available from a primary care network provider for the first 20 weeks|
|Acute||Unlimited at the primary care network service provider - subject to network formulary|
|Over the counter (OTC)||Single member = 3 prescriptions
Family = 5 prescriptions
Thirteen conditions covered (see page 31 of the Member Guide))
Pathology out of hospital - subject to network GP referral and formulary tests
|Radiology||Out of hospital - subject to network GP referral and formulary tests|
Optical benefit available per beneficiary every 24 months
1 optical test per beneficiary per year
Subject to use of primary care network service provider and protocols
|Basic dentistry||Per beneficiary per annum:
• one dental examination
• eight primary extractions
• 4 fillings as per protocol (meaning automatic payment), additional fillings require
|External prostheses||Per family = R6 000|
|Out-of-hospital procedures covered by the Essential Benefit Option subject to use of
a network provider
|0300||Stitching of soft-tissue injuries: Stitching of wound (with or without local anaesthesia).
Including normal after-care.
|0301||Stitching of soft-tissue injuries: Additional wounds stitched at same session (each).|
|0307||Excision and repair by direct suture. Excision nail fold or other minor procedures of similar magnitude.|
|0308||Each additional small procedure done at the same time.|
|0255||Drainage of subcutaneous abscess onychia, paronychia, pulp space or avulsion of nail.|
|0259||Removal of foreign body in muscle or tendon sheath: simple (not to be used for post-operative
removal of Kirschner wires or Steinmann pins).
|2133||Circumcision: Clamp procedure.|
|0877||Limb cast (excluding after-care).|
|1232||Electrocardiogram: Without effort|
|1233||Electrocardiogram: With and without effort.|
|1136||Nebulisation (in rooms).|
|Medical and surgical appliances (in- and out-of-hospital)||The following appliances are subject to the annual limit of R2 620 per family subject to motivation and pre-authorisation|
|Glucometers||R790 per beneficiary every 2 years|
|Nebulisers||R790 per family every 3 years|
|Other Appliances – once every 4 years||Subject to clinical protocols and submission of a motivation/quote. Please note that hearing aids are not covered on the Essential option|
|Out-of-Hospital Procedures subject to use of a network provider||11 Procedures covered out of hospital. Refer to list above for the detailed information|
|Free Hello Doctor consults||Telephonic consults via HELLO DOCTOR. Talk or text a doctor on your phone, anytime, anywhere, in any language – for free|
Out-of-area or emergency visits
Per family = three visits to a maximum of R1 000
1 visit per family subject to the Specialist benefit limit
Refer to pages 3 and 7 of 2021 Member Guide for the detailed benefits on free early detection, preventative and ante-natal care.
|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.
|Public hospital||Unlimited treatment in accordance with Scheme protocols|
Resuscitation and stabilisation only
|GPs and specialists||Unlimited treatment in a state facility in accordance with Scheme protocols|
|To-take-out medicine||Up to 7 days|
|Internal Prostheses||Per family = R9 000 where approved during hospital admission|
|Oncology||Where approved during hospital admission Subject to state and managed care protocols|
|Pathology||Where approved during hospital admission Subject to state and managed care protocols|
|Radiology||Where approved during hospital admission Subject to state and managed care protocols|
|Confinement||Treatment in accordance with Scheme and state protocols
Patient will be referred to a state facility for specialist care and the confinement.
Refer to page 7 and 16 for additional information
|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.