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OPTIMUM OPTION

This traditional and first-class plan provides members with comprehensive cover which includes extensive day to day benefits paid from the insured benefits and unlimited hospital cover. The option to choose if you would like a choice of providers.

MONTHLY CONTRIBUTION

MEMBERADULTCHILD
R7 474R6 362R1 872

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 pg 58 of 2021 Member Guide.

ANY PROVIDER
Day-to-day limit

M0 – R27 700
M1 – R38 600
M2 – R44 900
M3+ – R52 700

General practitioners (GPs) and specialists Subject to day-to-day limit
Medicines
Acute

M0 – R12 540
M1 – R13 580
M2 – R15 990
M3 – R17 450
M4+ – R18 600

Over the counter (OTC) R230 per event per day
Chronic benefit
Benefits are subject to registration onto the chronic management programme
Provider - Any provider 26 conditions covered as per the chronic disease list and prescribed minimum benefits. Refer to page 18 for more information on co-payments
Optometry

Per beneficiary = 1 composite eye examination
Per beneficiary = a frame of up to R1 355 and 2 lenses every 24 months
OR
Contact lenses of up to R2 280 instead of glasses per year

Dentistry:
Basic

Single member = R2 450
Family = R4 940

Specialised

Single member = R14 280
Family = R21 200

Auxiliary services

Sub-limits

At a preferred provider, subject to auxiliary sub-limit and day-to-day limits

Single member = R5 330
Family = R16 100

ADDITIONAL BENEFITS (paid from risk benefits)
Chronic medicine
Non-CDL chronic medicine limit

26 conditions – unlimited – plus 28 conditions, subject to sub-limits:

M0 – R6 900
M1 – R13 800
M2 – R14 900
M3 – R17 200
M4 – R19 000
M5+ – R20 100

Co-payment for non-formulary medicine 20%

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 9 for detailed information.

Medical and surgical appliances General per family = R10 400
Sub-limits to Appliance Benefit:
Glucometer per beneficiary every 2 years R820
Nebuliser per family every 3 years R820
Hearing aids

Per beneficiary every 3 years

Hearing aid maintenance

 

Unilateral = R12 200
Bilateral = R24 500
R1 100 per family per annum

External Prosthesis Per family per annum = R29 000
Patient care programmes (Diabetes, HIV, oncology) Subject to registration and managed care protocols

IN-HOSPITAL BENEFITS

ANY HOSPITAL
Subject to pre-authorisation and managed care protocols
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 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 R1200 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
Specialist – subject to preferred provider rates
To-take-out medicine Up to 7 days
Organ transplant (non-PMB cases)

Per family = R67 800 limit includes harvesting and transportation costs National donor only

Internal Prostheses Per family per annum = R47 000
Refractive eye surgery Per beneficiary per eye = R5 840; maximum of R11 680 for both eyes once per lifetime
Reconstructive surgery Per family = R67 800
MRI, CT, PET and radio isotope scans Per family per annum = 2 scans from risk thereafter from the annual day-today limit subject to clinical protocols and pre-authorization
Alternate care instead of hospitalisation Per family = 30 days to a maximum of
R41 200 per event subject to clinical protocols and pre-authorization
Mental health (in- and out-of-hospital) 100% of Scheme rate – Subject to clinical protocols and pre-authorization
Alcohol and drug rehabilitation 100% of negotiated rate, at a South African National Council on Alcoholism and Drug Dependence (SANCA)-approved facility
Subject to clinical protocols
Dialysis Unlimited and subject to use of preferred provider, clinical protocols and preauthorization
Oncology Unlimited clinical protocols and pre-authorization
Pathology and radiology Unlimited subject to clinical protocols
General dentistry Subject to day-to-day limit and sublimits
Ambulance transport Emergency road and air transport subject to use of the designated service provider, clinical protocols and pre-authorization

EXCLUSIONS

General exclusions as set out in the Annexure D of the Rules

Dental exclusions as set out in Annexure F of the Rules