CLASSIC OPTION
This new generation savings option provides members with the flexibility and independence to manage their own day- to-day expenses rich hospital cover; 26 CDL and 10 non-CDL conditions. Members on the Classic Network option can enjoy significant savings on their monthly contributions and still enjoy
comprehensive benefits.
ANNUAL SAVINGS LIMIT (ASL)
This is the portion of your monthly contribution that is allocated to a savings account that is held in the principal member’s name. The money in this account is used to pay for out-of-hospital medical expenses
| OPTION | MEMBER | ADULT | CHILD |
|---|---|---|---|
| Classic | R9 096 | R7 716 | R2 280 |
MONTHLY CONTRIBUTION
| OPTION | MEMBER | ADULT | CHILD |
|---|---|---|---|
| Classic | R5 050 | R4 286 | R1 264 |
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.
OUT-OF-HOSPITAL BENEFITS
Not sure what we mean? Refer to glossary on page 73 of the Member Guide.
Day-to-day benefits on the Classic and Classic Network options are subject to your Annual Savings Limit (ASL), which covers non-PMB, out-of-hospital claims such as GPs, dentists, specialists, medication, optometrists, etc. Once you have exhausted your ASL, you will need to pay for any additional day-to-day claims. A portion of your monthly contribution is allocated to your ASL. The ASL amount is calculated for a period of 12 months or if you join the Fund during the year, the amount will be calculated on a pro-rata basis. At the end of the year, any unused savings will carry over to the next year.
| CLASSIC NETWORK | |
| General practitioners (GPs) and specialists | Subject to ASL |
| Telehealth | Subject to ASL Scheme rates and managed care protocols apply Please call 0861 000 300 for more information |
| Medicines Acute Over-the-counter (OTC) Preventative medicines Contraceptives: oral, and injectables Devices subject to pre-authorisation |
Subject to ASL R265 per event per day Paid from ASL – refer to page 13 of the Member Guide R1500 per female beneficiary up to the age of 45 years per annum |
| Chronic benefit Benefits are subject to registration onto the chronic management programme |
Provider - Network pharmacy 26 conditions covered as per the chronic disease list and prescribed minimum benefits Refer to page 20 of the Member Guide for more information on co-payments |
| Optometry Subject to ASL |
Per beneficiary: 1 composite eye examination, a frame of up to R1 045 and 2 lenses every 24 months OR contact lenses of up to R1 530 instead of glasses per year Members may request frames and lens enhancements to be paid from their savings if the amount exceeds the above amounts Members may utilise positive savings for claim values above the annual optometry limits. Please call 0861 000 300 for more information |
| Dentistry: Basic and specialised Please note that, while dentures are covered, there is a limit of 1 set of dentures every 4 years per beneficiary. General anaesthetic is available for children under the age of 8 for extensive basic treatment and this is limited to once every 24 months per beneficiary. Cover is available for the removal of impacted wisdom teeth in theatre but must be pre-authorised by emailing a detailed quotation and clear panoramic radiograph to the dental department. |
Subject to ASL |
| Auxiliary services | Subject to ASL |
ADDITIONAL BENEFITS (not paid from ASL)
| CLASSIC NETWORK | |
| Chronic medicines
Non-CDL chronic medicine |
26 conditions – unlimited (refer to page 20 of the Member Guide), M – R5 750 |
| Network provider | Scheme network pharmacy |
| Co-payment for non-formulary medicine | 20% |
| Co-payment for use of non-network provider | 30% |
| Free Hello Doctor consults | Telephonic consults via HELLO DOCTOR. Talk or text a doctor on your phone, anytime, anywhere, official language – for free. Refer to page 10 for detailed information |
| Medical and surgical appliances | |
| General appliances per family per annum | R16 300 |
| Sub-limits to Appliance Benefit: Glucometer per beneficiary every 2 years |
R920 |
| Nebuliser per family every 3 years | R920 |
| External Prosthesis per family per annum | R28 740 |
| MRI, CT, PET and radio isotope scans | R16 650 per scan Per family = 2 scans paid from risk benefits thereafter ASL Subject to pre-authorisation and managed care protocols |
| Hearing aids |
Subject to medical and surgical appliance limit every 3 years |
| Hearing aid maintenance | R1 230 per beneficiary per annum Subject to Medical and Surgical Appliance Benefit |
| Mental health | Subject to ASL |
| Extra consultations and medicine(Only once ASL reaches a balance of R300 or less. Medication limit R300) | Single member = 2 visits Family = 5 visits |
| Patient care programmes (Diabetes, HIV, oncology) | Subject to registration and managed care protocols |
IN-HOSPITAL BENEFITS
| Subject to pre-authorisation and managed care protocols |
CLASSIC |
| IMPORTANT: Treatment performed in-hospital 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. | |
| In-hospital limits | Any hospital |
| State and private hospital | Unlimited |
| CO-PAYMENT FOR SPECIALIZED PROCEDURES/TREATMENT (This co-payment is only applicable to benefit below and not the entire benefit) |
|
| Procedure/treatment Gastroscopy, colonoscopy, sigmoidoscopy, arthroscopy, joint replacements, diagnostic laparoscopy, urological scopes and facet joint injections |
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 | At Scheme rate Specialists subject to preferred provider rates |
| To-take-out medicine | Up to 7 days |
| Organ transplant (non-PMB cases) | Per family = R76 070 (limit includes harvesting and transportation costs) National donor only |
| Internal Prostheses | Per family per annum = R45 275 |
| Refractive eye surgery |
Per beneficiary per eye = R6 540 maximum of R13 080 for both eyes once per lifetime |
| Reconstructive surgery (as part of PMBs) | Per family = R75 950 |
| MRI, CT, PET and radio isotope scans | R16 650 per scan Per family = 2 scans paid from risk thereafter from ASL subject to motivation Subject to clinical protocols and pre-authorisation |
| Alternate care instead of hospitalisation | Per family = 30 days to a maximum of R42 815 per event subject to clinical protocols and pre-authorisation |
| Mental health (in- and out-of-hospital) | 100% of Scheme rate subject to clinical protocols and pre-authorisation |
| Alcohol and drug rehabilitation | 100% of negotiated rate, at a South African National Council on Alcoholism and Drug Dependence (SANCA)- approved facility |
| Dialysis | Subject to use of preferred provider, clinical protocols and pre-authorization |
| Oncology in and out of hospital Non-PMB casesPMB cases |
Per family = R500 000 per annum 20% co-payment after limit has been reached Subject to clinical protocols and pre-authorisation Unlimited |
| Pathology and basic radiology | At Scheme rate |
| General dentistry | Subject to ASL and dental protocols |
| Ambulance transport | Emergency – road and air Subject to use of the designated service provider, clinical protocols and pre-authorisation |
EXCLUSIONS
General exclusions as set out in the Annexure D of the Rules
Dental exclusions as set out in Annexure F of the Rules