JustNat Enterprises     

    Munimed Benefits   

 

Alpha (Plan A) 

 

.

Type of Benefit

 Munimed Alpha 2002
. OVERALL ANNUAL MAXIMUM NONE
No. Service Category  
1 Hospitalisation, Theatre fees and Intensive and High Care unit if prescribed by a doctor
Subject to obtaining a PAR
  1.1   Provincial and State Hospitals 100% of BHF Unlimited
  1.2   Private hospitals 100% of BHF Unlimited
  1.3   Psychiatric Hospitals 100% of BHF tariff
Limited to R25 000
2 Operations and Confinements 100% of BHF
No limit
3 Organ Transplants
(subject to case management and pre-authorisation)		 100% of BHF Unlimited
4 Radiology and Pathology
While hospitalised		 100% of BHF Unlimited
5 Internal Prosthesis 100% of cost
R20 000 per family per annum
6 Blood Transfusions 100% of BHF Unlimited
7 MRI & CAT scans 
(in or out of hospital)
(subject to pre-authorisation)		 100% of BHF Unlimited
8 Radiotherapy & Chemotherapy
(subject to case management)		 100% of BHF Unlimited
9 Sub-acute facilities, Hospice, Nursing Services, Practicing Nurses and Rehabilitation
(subject to case management)		 100% of cost Unlimited
10 Ambulance Services 100% of cost
Subject to preferred provider
11 Statutory Prescribed Minimum Benefits Unlimited (preferred services is rendered in a state hospital)
12 Dialysis

Haemodialysis
Peritonial dialysis

(Subject to case management and pre-authorisation)

 100% of BHf to a maximum of:
R830 Per treatment
R2100 Per beneficiary per month
13 Chronic Medication
Discount on chronic medication is to the benefit of the member.		 80% of BHf tariff
20% Payable by member directly to service provider
R10 000 per beneficiary to a maximum of R20 000 per family
14 GP's & Specialists .
 
14.1   Out-of-hospital: including: 
X-rays
Radiology
Pathological services
100% of BHF tariff, limited to
M R3500
M+1 R4400
M+2 R4800
M+3 R5200
M+4+ R5600
 
14.2   In-Hospital:
X-rays
Radiology
Pathological services
 100% of BHF 
No limit
15 Prescribed Medicine
Acute (including homeopathic medication)
100% of BHF tariff, limited to:
M R2400
M+1 R3000
M+2 R3300
M+3 R3600
M+4+ R3900

Levy of R15 payable by member directly to service provider

Over-the-counter M R450; M+1+R600
16 Dentistry
(Basic, intermediate & advanced)
100% of BHF tariff, limited to:
M R3750
M+1 R6000
M+2 R6500
M+3 R7000
M+4+ R7500

Gold fillings: R240

17 Joint overall out-of-hospital limit for the following GP's, Specialists, Opthalmologists & Homeopaths
Basic, Intermediate & Advanced Dentistry
Acute & Self medication
Radiology and Pathology
100% of BHF tariff, limited to:
M R7000
M+1 R10000
M+2 R11000
M+3 R12000
M+4+ R13000
18 Auxiliary Services 100% of BHF tariff, limited to:
  18.1   (Chiropractors, occupational therapists, physiotherapists, homeopaths, dieticians, speech therapists & clinical psychologists) R4000 per family
  18.2   External Prosthesis & Ortheopaedic Appliances 100% of cost limited to:
R5000 per family
  18.3   Hearing Aids Maximum of R10 000 per family
  18.4   Optical 100% of SAOA tariff
    18.4.1   Frames R400 per beneficiary to a maximum of 2 frames per family
    18.4.2   Lenses & Contact Lenses R1500 per beneficiary to a maximum of R2500 per family
Contact lenses: R1320 add per family
    18.4.3   Eye tests 1 test per beneficiary per annum
No benefit for sunglasses
19 AID FOR AIDS
(Registration for this program is compulsory)		 100% of cost.  Maximum of R25 000 per beneficiary per annum for medication
20 Medical Savings Account None
21 Savings Levels .
22. EXCLUSION IN RESPECT OF OTHER INSTITUTIONS
Services rendered in a nursing home or similar institution, convalescent home, old-age home or any other place not mentioned in service category 4, will be excluded from benefits.

MEDICINE AS PRESCRIBED AND SUPPLIED BY A HOSPITAL IS NOT SUBJECT TO THE LIMIT FOR PRESCRIBED MEDICINE.

23. DENTAL SERVICES
Benefits regarding dental services are subject to the maximums and limits per financial year as defined in service category 16.
24. SPECTACLES AND CONTACT LENSES
Benefits regarding dental services are subject to the maximums and limits per financial year as defined in service category 18.4.
25 AUXILIARY SERVICES

25.1     ORTHOPAEDIC APPLIANCES

ALPHA (PLAN A)
Maximum of R5000 per family per year.
(Refer to service category 18.2)

25.2     HEARING AIDS

ALPHA (PLAN A)
Maximum of R10 000 per family per year.
(Refer to service category 18.3)

 

26 PREGNANCY AND CONFINEMENTS
  • Benefits as under service categories 1, 2, 15 and 18 above, where applicable, also apply to pregnancies and confinements and will also be granted if the child is stillborn or dies.
  • The granting of benefits is subject to the submission of a birth certificate together with the relevant account on the prescribed claim form.
  • Benefits are further subject to the member's participation in the Scheme's Maternity Management Programme.
27 LIMITS

(Refer to point 28)

27.1     Conditions in respect of benefits on prescribed medicine:

(Refer service category 15)

27.1.1 A copy of the prescription containing the cost of the prescribed medicine must be submitted.
27.1.2 A prescription covers all the medicine prescribed per case for one person for the condition under treatment.
27.1.3 The benefits per prescription are limited to the quantity required for one month of use.
27.1.4 For homeopathic medicines, Service category 15 applies.
27.1.5.1 No contribution is made on the cost of patent medicines, household remedies, vitamins (unless for therapy), vitamin and stimulant mixtures, stimulants, tonics, patent foods including baby food, slimming aids and contraceptives, unless the abovementioned remedies have a "NAPPI" code, then it can be obtained under the selfmedication benefit.
27.1.5.2 A prescription is considered to include all the medicine prescribed by a medical practitioner or dentist, or anyone legally authorized to one person for an illness under treatment for a period not exceeding one month, unless the Board should decide otherwise.

27.2     Levies - Alpha (Plan A)

An additional co-payment of R15,00 per prescription of the gross amount is payable directly to the supplier, by the member, on prescribed medicine.

27.3     Life-supporting medication

Life-supporting medication benefits is contained in Service category 13 and must be obtained with a prescription.

It is expected of the member to submit a report every 6 (six) months as proof that life-supporting medication should be continued.

28 MAXIMUM BENEFITS

28.1  Day-to-day expenses

These expenses, as well as the disciplines relating to these expenses, are contained in Service category 17.

28.2  Overall maximum

Only Omega (Plan C) is subjected to an overall maximum of R350 000 per annum.

28.3  Psychiatric Hospitals

This benefit is limited to R25 000 per dependant per annum for all the plans.

28.4  Internal Prosthesis

Limited to R20 000 per family per year for all plans.

28.5  Kidney dialysis

Limited as per Service category 12.

29 AIDS/ HIV PROGRAMME (Aid for Aids)
Benefits as per Service category 19 is applicable.
30 MEDICAL SAVINGS ACCOUNT
Detail regarding the medical savings accounts and the savings levels are contained in Service category 20 and 21.
31 SERVICE DATE
All claims for benefits are calculated according to the date of service and not according to the date on which the claim was submitted.
32 TRANSFERABILITY OF BENEFITS
Benefits are not transferable.

Click here for contributions