HOSPICARE OPTION
Targeted at members requiring hospital cover primarily. The extensive in and out of hospital benefits are for PMB conditions/treatment only with some value-added benefits and 26 Chronic conditions. Members on the Hospicare Network option can enjoy significant savings on their monthly contributions and still enjoy comprehensive benefits.
MONTHLY CONTRIBUTION
| OPTION | MEMBER | ADULT | CHILD |
|---|---|---|---|
| Hospicare | R3 024 | R2 558 | R751 |
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.
| HOSPICARE | |
| Day-to-day | As part of an approved treatment plan |
| General practitioners (GPs) and specialists | 271 DTPs; PMB treatment only Specialists subject to preferred provider rates |
| Medicines Acute Chronic Network provider Co-payment for non-formulary medicine Co-payment for non-network provider |
271 DTPs; PMB treatment only |
| Non-CDL chronic medicine limit | 271 DTPs; PMB treatment only |
| Optometry | 271 DTPs; PMB treatment only |
| Dentistry Basic and specialised | 271 DTPs; PMB treatment only |
| Auxiliary services | 271 DTPs; PMB treatment only |
ADDITIONAL BENEFITS
| ADDITIONAL BENEFITS | HOSPICARE |
| Free Hello Doctor consults |
Telephonic advice via HELLO DOCTOR. Talk or text a doctor on your phone, anytime, anywhere, in any official language – for free Refer to page 10 for detailed information |
| Maternity |
• 12 antenatal visits |
| Medical and surgical appliances | 271 DTPs; PMB treatment only |
| Hearing aids | 271 DTPs; PMB treatment only |
| Mental health | 271 DTPs; PMB treatment only |
| Child immunisations | Up to the age of 6 years, as per Department of Health protocols |
| Patient care programmes (Diabetes, HIV, oncology) | Subject to registration and managed care protocols |
IN-HOSPITAL BENEFITS
| HOSPICARE | |
| 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. | |
| All services are subject to preauthorisation and managed care protocols | Any hospital – PMBs only |
| Public and private hospital | Unlimited – PMBs only |
| GPs and specialists | 271 DTPs; PMB treatment only |
| To-take-out medicine | Up to 7 days |
| Organ transplant* | Unlimited – PMBs only |
| Prostheses | Unlimited – PMBs only |
| Reconstructive surgery | Unlimited – PMBs only |
| MRI, CT, PET and radio isotope scans | Unlimited – PMBs only |
| Alternate care instead of hospitalisation | Unlimited – PMBs only Subject to clinical protocols and pre-authorization |
| Mental health | 100% of Scheme rate subject to managed care protocols |
| Alcohol and drug rehabilitation | 100% of negotiated rate, at a South African National Council on Alcoholism and Drug Dependence (SANCA)-approved facility. Subject to managed care protocols |
| Dialysis | Unlimited – PMBs only |
| Oncology Treatment covered at DSP rates if a network provider is used | Unlimited – PMBs only |
| Pathology and radiology | Unlimited – PMBs only |
| Ambulance transportTreatment covered at DSP rates if a network provider is used | Road and air transportation PMB Only Subject to use of preferred provider, clinical protocols and pre-authorization |
| ADDITIONAL BENEFITS | |
| Only the 7 non-PMB procedures listed are covered in hospital at a network provider and is paid at the Scheme rate | Tonsillectomy Adenoidectomy Basic dentistry – up to the age of 8 Grommets Carpal tunnel Varicose veins Bunionectomy |
*Organ transplant benefit includes:
- Heart, liver and kidney transplants, including harvesting and transportation costs
- Corneal transplant, including harvesting and transportation costs
All requests will be subject to clinical protocols and use of a national donor only.
EXCLUSIONS
Unless stated Non-PMB procedures in hospital
All non-PMB general exclusions as set out in the Annexure D of the Rules
All non-PMB dental exclusions as set out in Annexure F of the Rules