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
| MEMBER | ADULT | CHILD |
|---|---|---|
| R7 922 | R6 744 | R1 984 |
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 |
M – R29 270 |
| General practitioners (GPs) and specialists | Subject to day-to-day limit |
| Medicines Acute |
M – R13 250 |
| Over the counter (OTC) | R240 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 590 |
| 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 635 |
| 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 290 |
| 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 = R10 990 |
| Sub-limits to Appliance Benefit: | |
| Glucometer per beneficiary every 2 years | R865 |
| Nebuliser per family every 3 years | R865 |
| Hearing aids
Per beneficiary every 3 years Hearing aid maintenance |
Unilateral = R12 890 |
| External Prosthesis | Per family per annum = R30 650 |
| 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 = R71 660 limit includes harvesting and transportation costs National donor only |
| Internal Prostheses | Per family per annum = R49 670 |
| Refractive eye surgery | Per beneficiary per eye = R6 170; maximum of R R12 340 for both eyes once per lifetime |
| Reconstructive surgery | Per family = R71 660 |
| MRI, CT, PET and radio isotope scans | R15 000 per scan per family per annum = 2 scans from risk thereafter from the annual day-today limit subject to clinical protocols and pre-authorisation |
| Alternate care instead of hospitalisation | Per family = 30 days to a maximum of R43 545 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