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Necesse R11001 and more - 2021

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Type of Medical Aid Plan: 
Capitation
Medical Aid Year: 
2021
Income Level: 
11001+
Day to day Benefits: 

All services by network providers with the Necesse network GP as the primary point of access for; consultations, medicine, physiotherapy, radiology and pathology. Dental and optical benefits. Protocols and sub-limits apply

In Hospital Benefits
Are you prepared to use designated hospitals?: 
Yes
Hospital Rate of Payment: 
Unlimited at 100% of Medihelp Tariff (MT)
Hospitals: 

Necesse network hospital for all hospital admissions

Casualty / Emergency Visits: 
Emergency and non-network GP visits: 80% 0f MT: M = R1 150; M+= R2 350 for consults, medication and radiology requested by a non-network GP. Pathology at Lancet and PathCare only. No benefit for facility fee
Specialists: 
Unlimited at 100% of MT
Other healthcare professionals eg. Physio, Occupational, Dietician: 
100% of MT. Limited to M = R2 100 pa, M+ = R3 300 pa
Radiology and pathology: 
100% of MT. Limited to R31 700 pfpa
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
Performed in specialist rooms; see "Specialist care" under day-to-day benefits
MRI and CT scans: 
Subject to pre-authorisation, clinical protocols and requested by a specialist on referral by a Necesse network GP. 100% of MT. Limited to R11 100 pfpa in or out of hospital
ICU and High Care: 
Unlimited at 100% of MT
Dialysis: 
PMB only. Subject to pre-authorisation and clinical protocols. 100% of cost
Organ Transplants: 
PMB only. Subject to pre-authorisation and clinical protocols. Unlimited at 100% of cost
Oncology / Cancer: 
PMB only. Subject to pre-authorisation, protocols, a DSP and registration on the Medihelp Oncology Programme. 100% of cost
Neck and Back Operations: 
No Benefit
Joint Replacements: 
No Benefit
Prosthesis: 

Subject to pre-authorisation, clinical protocols and case management In hospital: 100% of MT. Limited to R23 900 pbpa. PMB prostheses to be obtained from a DSP; EVARS prosthesis; Vascular or cardiac prostheses; Health-essential functional prostheses; Intraocular lenses; Reconstructive or restorative surgery prostheses

Medical and Surgical Appliances: 
Services in or out of hospital, prescribed by a Necesse network GP or specialist on referral by a network GP. 100% of MT. Sub-limits apply for non-PMB cases
Maternity Confinements: 
Subject to pre-authorisation and clinical protocols. Services rendered by a Necesse network specialist on referral by a network GP. 100% of MT. R27 300 available for an elective caesarean section
In Hospital Dentistry: 
PMB only. Subject to pre-authorisation and DSP's managed care protocols. Limited to extensive treatment for children younger than 5 years. 100% of MT
Take home Medicine: 
100% of the MT up to R360 per admission
Rehabilitation, Hospice and Step-down facilities: 
Subject to pre-authorisation and prescribed by a medical doctor. 100% of MT. Limited to R23 100 pfpa
Treatment for Mental Health: 
Subject to pre-authorisation, protocols and services rendered in an approved network facility and requested by a network GP or specialist on referral by a network GP. 100% of cost
HIV / AIDS: 
Subject to registration on Medihelp's HIV/AIDS programme with LifeSense. 100% of cost
Ambulance Service: 
Subject to pre-authorisation and protocols. Unlimited with Netcare 911
International Travel Benefit: 
No Benefit
Day-to-day benefits
GP consultations: 

Necesse network GP: 9 consultations pbpa. Emergency and non-network GP visits: 80% of MT: M = R1 150; M+ = R2 350 for consults, medication and radiology requested by a non-network GP. Pathology at Lancet and PathCare only

Specialist consultations: 

Subject to referral by a Necesse network GP, clinical protocols and pre-authorisation, including 1 follow-up visit. 100% of MT: M = R3 300; M+= R4 600. For: consultations; surgical and non-surgical procedures; diagnostic endoscopic procedures performed in the specialist’s rooms; standard radiology and pathology (at Lancet and PathCare) requested by a specialist; acute medication prescribed, administered and dispensed by a specialist or obtained from a network pharmacy

Acute medicine: 

Prescribed by a Necesse network GP and dispensed by network GP or network pharmacy. Benefit only for medicines on the Necesse acute medicine formulary or dental medicine formulary

Over-the-counter (OTC) Medicine: 

Obtained from a network pharmacy R110 per event, R300 pbpa

Optometry benefits: 
Services must be pre-authorised by PPN and services rendered by a PPN provider per 24 month cycle. 1 composite eye test and spectacles or contact lenses
Basic dentistry: 
Subject to DSP's managed care protocols and services rendered by a network dentist
Specialised Dentistry: 
No Benefit
Orthodontics: 

No Benefit

MRI and CT Scans (Out of Hospital): 
Subject to pre-authorisation, clinical protocols and requested by a specialist on referral by a Necesse network GP. 100% of MT. Limited to R17 100 pfpa in or out of hospital
Radiology and Pathology: 
Subject to a list of approved standard item codes and requested by a Necesse network GP. 100% of MT. DSP's for pathology and radiology
Pregnancy benefits: 
Shared with 9 Necesse network GP consultations. "Added insured benefits" for 2 additional gynaecologist consultations and 2 x 2D sonars
Physiotherapy and Occupational Therapy day to day: 
Requested by a Necesse network GP or specialist on referral by a network GP. 100% of MT. Limited to M = R2 100 pa; M+= R3 300 pa
Chronic Conditions
Provider: 
Dispensing Necesse network GP or network pharmacy
Chronic Conditions: 

Diagnosis, treatment and care costs of 26 chronic conditions that fall under the Prescribed Minimum Benefit (PMB) Chronic Disease List (CDL), issued by the Council for Medical Schemes. Subject to pre-authorisation, protocols and the Necesse formulary

Additional Chronic Conditions: 
None
Preventative Care Benefits
Preventative Benefits: 

Payable at 100% of MT. 1x blood glucose and 1x cholesterol test , HIV testing, counselling and support by a Necesse network GP, tetanus and flu vaccine. Age and frequency specific tests for women: pap smear, mammogram and bone mineral density scan, prostate specific antigen for men. Child flu vaccines

Total Contributions
Total Contribution Main Member: 
2724.00
Total Contribution Adult: 
2130.00
Total Contribution Child*: 
1182.00
Necesse 11000 and more
Medical Aid Plan Name Term: 
Necesse