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ESSENTIAL OPTION

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:

MONTHLY CONTRIBUTION

SALARY BANDMEMBERADULTCHILD
R0 – R3 100R385R230R155
R3 101 – R6 650R410R245R155
R6 651 – R9 750R585R355R230
R9 751 +R675R410R275

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

Click here to look up your Medication Formulary

View the Chronic Conditions covered by the Essential Option

OUT-OF-HOSPITAL BENEFITS

Not sure what we mean? Refer to glossary on pg 58 of the 2021 Member Guide.

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
Prescribed medicines
Acute Unlimited at the primary care network service provider - subject to network formulary
Over the counter (OTC) Single member = 3 prescriptions
Family = 5 prescriptions
Chronic

Thirteen conditions covered (see page 31 of the Member Guide))
Subject to use of a primary care network provider and protocols
No benefit if a non-network service provider is used

Pathology

Pathology out of hospital - subject to network GP referral and formulary tests

Radiology Out of hospital - subject to network GP referral and formulary tests
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
No benefit if a non-network provider is used

Basic dentistry Per beneficiary per annum:
• one dental examination
• scaling
• eight primary extractions
• 4 fillings as per protocol (meaning automatic payment), additional fillings require
pre-authorisation
• polishing
External prostheses Per family = R6 000
Out-of-hospital procedures covered by the Essential Benefit Option subject to use of
a network provider
TARIFF TARIFF DESCRIPTION
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
ADDITIONAL BENEFITS
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

Paedriatric visits

1 visit per family subject to the Specialist benefit limit

Wellness Benefit

Refer to pages 3 and 7 of 2021 Member Guide for the detailed benefits on free early detection, preventative and ante-natal care.

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.
Public hospital Unlimited treatment in accordance with Scheme protocols
Private hospital

Resuscitation and stabilisation only
Subject to pre-authorisation within 48 hours of admission and managed care protocols

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.

EXCLUSIONS

  • General exclusions as set out in the Annexure D of the Rules
  • Dental exclusions as set out in Annexure F of the Rules
  • Alcoholism and drug dependency
  • Cochlear Implants
  • Corneal transplants
  • Dentistry in hospital
  • Infertility
  • Kidney dialysis
  • Refractive eye surgery