OPTIMUM OPTION
This traditional and first-class option provides members with comprehensive cover, which includes extensive day-to-day benefits; unlimited private hospitalisation; 26 CDL plus 28 non-CDL conditions. The option to choose if you would like a choice of providers.
MONTHLY CONTRIBUTION
| MEMBER | ADULT | CHILD |
|---|---|---|
| R8 469 | R7 209 | R2 121 |
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 77 of Member Guide.
| ANY PROVIDER | |
| Day-to-day limit |
M – R31 020 |
| General practitioners (GPs) and specialists | Subject to day-to-day limit |
| Telehealth |
Subject to day-to-day limit |
| Medicines Acute |
M – R14 040 |
| Over the counter (OTC) | R1500 per female beneficiary up to the age of 45 years per annum |
| Contraceptives: oral, and iinjectables Devices subject to pre-authorisation |
R255 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 22 for more information on co-payments |
| Optometry |
Per beneficiary = 1 composite eye examination |
| Dentistry: Basic |
Single member = R2 849 |
| Specialised |
Single member = R15 090 |
| Auxiliary services
Sub-limits |
At a preferred provider, subject to auxiliary sub-limit and day-to-day limits
Single member = R5 975 |
| ADDITIONAL BENEFITS (paid from risk benefits) | |
| Chronic medicine | |
| Non-CDL chronic medicine limit |
26 conditions – unlimited – plus 28 conditions, subject to sub-limits: M – R7 720 |
| 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 10 for detailed information. |
| Medical and surgical appliances | General per family = R11 650 |
| Sub-limits to Appliance Benefit: | |
| Glucometer per beneficiary every 2 years | R915 |
| Nebuliser per family every 3 years | R915 |
| Hearing aids
Per beneficiary every 3 years Hearing aid maintenance |
Unilateral = R13 660 |
| External Prosthesis | Per family per annum = R32 480 |
| 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 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 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 | Unlimited Specialist – 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 |
| Internal Prostheses | Per family per annum = R52 650 |
| Refractive eye surgery | Per beneficiary per eye = R6 540; maximum of R R13 080 for both eyes once per lifetime |
| Reconstructive surgery | Per family = R75 950 |
| MRI, CT, PET and radio isotope scans | R15 900 per scan per family per annum = 2 scans from risk thereafter from the annual day-to-day limit subject to clinical protocols and pre-authorisation |
| Alternate care instead of hospitalisation | Per family = 30 days to a maximum of R46 150 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-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