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Benefit Options and Exclusions

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Makoti offers two benefit options. You need to choose one of these options, taking your healthcare needs and affordability into account.

Please note that cover provided is for healthcare services rendered within the borders of South Africa and is paid at 100% of the medical scheme tariff.

Option 1: Primary Option

Day-to-day benefits Please contact the 24-hour call centre on 0860 00 24 00 for pre-authorisations

  • GPs: Unlimited primary healthcare from your chosen general practitioner
  • Medicines: Unlimited acute and chronic medicine, as per the medication formulary
  • Over the counter medicine (OTC): Generic medicine limited to R346 per family per year

The following benefits are available, subject to pre-authorisation and referral by your chosen general practitioner:

  • Specialists: Prescribed Minimum Benefits only in State Hospitals
  • Radiology: CXR, suspected fractures of extremities and two obstetric sonars per pregnancy
  • Pathology: Cover is provided for the following pathology tests:
      4559 Liquid Based Cytology (1st)
      4566 Vaginal or cervical smears, each. Pathology Anatomical Exfoliative cytology
      4057 Glucose: Quantitative. Pathology Biochemical test blood
      4064 Glycosylated haemoglobin: chromatography. Pathology Biochemical test blood
      3762 Haemoglobin estimation. Pathology Haematology
      3797 Platelet count. Pathology Haematology
      3951 Quantitative Kahn, VDRL or other flocculation. Pathology Serology (RPR)
      3764 Grouping: A B and O antigens. Pathology Haematology
      3765 Grouping: Rh antigens. Pathology Haematology
      3785 Leucocytes: total count Pathology Haematology (WCC)
  • Ambulance services for medical emergencies. The Scheme has contracted with Lifemed ambulance service (0861 086 911) as its preferred provider for ambulance services. Please note that the Scheme will not provide transport cover for non-life-threatening situations.
  • Optometry: Limited to R905 per beneficiary every 24 months. This limit includes the costs of the eye test, frames and lenses. Optometry services must be pre-authorised via the call centre by phoning 0860 002 400. Cover will only be provided where it is necessary for correcting significant visual impairment. Lenses are subject to a refraction error of more than, or equal to, 0.5 dioptre. Please note that replacement of lost spectacles is not covered.
  • Dentistry: Benefit for consultations, fillings, extractions and prevention as per managed care protocols. All dentistry must be provided by an accredited dentist or dental therapist, after the dentist has obtained pre-authorisation from Dental Information Systems (Pty) Ltd at 0860 104 925. There is no benefit for specialised dentistry or dentures.

In-hospital Benefits:

  • All benefits are paid at 100% of the medical scheme tariff
  • Contact the 24-hour call centre on 0860 002 400 for pre-authorisations
  • Experienced risk managers review all hospital admissions to optimise care
  • Services accessed in State Hospitals only. The statutory Prescribed Minimum Benefits (PMBs) are covered in full as authorised, in respect of the relevant healthcare services as described in terms of section 67(1)(g) of the Medical Schemes Act including Emergency Stabilisation.

    Maternity: Confinement is covered at a state facility or at a Birthing Team unit, where available. A multidisciplinary team will manage the member’s pregnancy from confirmation of pregnancy to childbirth and compile a personalised care plan for each member. During the first trimester of pregancy the member must register for an assessment. Where members fall outside of the defined risk categories, they will be referred to either a Private or State Hospital by the Birthing Team after assessment. Cover in a Private Hospital is limited to a maximum of R25 000 per pregnancy. Birthing team units are currently available at the following facilities:

    • Netcare Rand Hospital – Johannesburg, Berea
    • Netcare Femina Hospital – Pretoria, Arcadia
    • JMH City Hospital – Durban Central
    • Pholoso Hospital
    • Netcare Polokwane

    Internal Prostheses: Limited to R49 690 per family per year.

    Option 2: Comprehensive Option

    Day-to-day benefits Please contact the 24-hour call centre on 0860 00 24 00 for pre-authorisations

    • GPs: Primary healthcare from your chosen general practitioner
    • Medicines: Acute and chronic medicine, as per the medication formulary
    • Over the counter medicine (OTC): Generic medicine limited to R360 per family per year

    The following benefits are subject to pre-authorisation and referral by your chosen general practitioner:

    • Specialists
    • Radiology
    • Pathology
    • Ambulance services for medical emergencies. The Scheme has contracted with Lifemed ambulance service (0861 086 911) as its preferred provider for ambulance services. Please note that the Scheme will not provide transport cover for non-life-threatening situations.

    The following benefits are provided by accredited providers and are subject to limits:

    • Optometry: Limited to R2 469 per beneficiary every 24 months. The limit includes the costs of the eye test, frames and lenses, including multi-focal lenses and contact lenses. Optometry services must be authorised via the call centre by phoning 0860 002 400. Cover will only be provided where it is necessary for correcting significant visual impairment. Lenses are subject to a refraction error of more than, or equal to, 0.5 dioptre. Please note that replacement of lost spectacles is not covered.
    • Dentistry: Benefit for consultations, fillings, extractions and prevention are as per managed care protocols. All dentistry must be provided by an accredited dentist or dental therapist, after the dentist has obtained authorisation from Dental Information Systems (Pty) Ltd at 0860 104 925. Specialised dentistry is subject to a limit of R3 337 per family per year, including root canal treatment and all periodontal treatment.

    Other Services

    • Clinical Psychology Limited to 8 consultations per family per year and subject to pre-authorisation.
    • Hearing Aids Limited to R3 235 per beneficiary every 4 years and subject to pre-authorisation.
    • External Prosthesis A maximum of R3 203 per member per annum for external orthopaedic prosthesis and including wheelchairs, walking frames, crutches and home oxygen. Glucometers limited to R300 per member every 24 months. Subject to pre-authorisation and clinical protocols.
    • Internal Prostheses Limited to R49 690 per family per year. Subject to pre-authorisation and clinical protocols. Cardiac stents limited to 3 stents, 1 per lesion.
    • Physiotherapy and Occupational Therapy A maximum of 20 treatments per family per annum and subject to preauthorisation.
    • Oncology (Chemotherapy, Radiotherapy, Radiology, Related consultations, Pathology) Limited to PMB level of care as authorised in terms of the ICON treatment plan. No benefit for Biologicals or Brachytherapy materials.
    • Immunisations/Vaccinations 1 Flu vaccination per beneficiary per year. 1 HPV vaccination for female beneficiaries between 9 and 27 years. 1 Pneumococcal vaccination (every 5 years) for all immune-compromised beneficiaries and beneficiaries older than 65 years.
    • Organ transplants/Kidney dialysis Subject to PMBs, clinical protocols and pre-authorisation.
    • Emergency room/casualty Medical necessities only.
    • Ambulance services Ambulance services for medical emergencies are available 24 hours a day and subject to pre-authorization by Lifemed, the preferred provider for Makoti Medical Scheme on 0861 086 911.

    Items not included (exclusions) for both Options

    The Makoti Medical Scheme will NOT cover the following costs subject to provisos in the Prescribed Minimum Benefits:

    • The treatment of obesity and its direct complications
    • Items or treatments that are not medically indicated
    • Wilfully self-inflicted injuries (e.g. suicide attempts)
    • Injuries arising from professional sport and speed contests
    • The hire of medical, surgical and other appliances
    • The cost of surgical stockings
    • Medical services provided by any person not registered with the Health Professions Council of South Africa, the South African Nursing Council or the Pharmacy Council
    • Recuperative holidays
    • Dental Extractions for non-medical purposes
    • Gold inlays
    • Unproven or experimental treatment
    • Cosmetic and reconstructive surgery, treatment and appliances
    • Frail care and convalescence
    • Employee medical examinations initiated by employer
    • Items or treatments which are not medically essential
    • Injuries where another party is responsible for the costs (e.g. Road Accident Fund or Workmen’s Compensation claims)
    • The treatment of drug, alcohol or any chemical substance dependency and the direct complications due to the abuse thereof
    • Roacccutaine and Retin A for the treatment of skin conditions
    • Contraceptives and contraceptive devices
    • Member related travelling expenses
    • Charges for appointments which a beneficiary fails to keep
    • Elective (non-emergency) after hours consultations
    • Telephonic consultations with healthcare providers
    • Medical examinations or mass inoculation of employees initiated by employers
    • All costs for any cosmetic procedures/treatment/medication, except if as a result of an accident, illness or disease. Operations for nasal or breast reconstruction except due to medical reasons. All costs for operations, medicines, treatment and procedures for obesity, cosmetic purposes, or of the member’s own choosing where this has no connection with any illness, presumed illness, accident or other medical disability:

    Please note:

    Third party claims

    If you are involved in a motor accident, your medical aid administrator will have a claim against the third party for medical expenses incurred. In order to go ahead with this claim, you or your dependant will be required to complete an “Accident Report” form.

    YOUR SERVICE PROVIDERS

    Your accredited general practitioner

    Members are required to select a general practitioner. As this is the only service provider that you will be able to use, you should therefore carefully consider who you would like to choose as your regular doctor. You can select a general practitioner of your choice who is easily accessible to you and Enablemed will attempt to contract with this doctor to enable them to provide you with the services as offered by the Scheme. It is important to understand that this will then be the only general practitioner you will be able to consult with (except in emergencies).

    Choosing a doctor and staying with one provider has many advantages. You will build a relationship of trust with your doctor who will get to know you and your unique requirements better. This approach avoids the risks of conflicting treatments and medicines that may occur if you consult more than one general practitioner. If you wish to change your general practitioner you can do so by completing the Doctor Choice Form.

    Dental Services are arranged through the Dental Information Systems (Pty) Ltd call centre available on 0860 104 925.

    MANAGED HEALTHCARE

    The services rendered by members of the healthcare profession for the benefit of a patient.

    The purpose of managed healthcare is as follows:

    • To provide you and your dependants with high quality healthcare protocols that have been developed by the Scheme, and which need to be followed to access your benefits
    • To keep healthcare affordable and accessible to as many people as possible
    • This will be done for you through your doctor and the staff of the call centre

    Assistance with managed healthcare will be given through your doctor and the staff at the Call Centre.

    NB: All services are subject to pre-authorisation and clinical protocols unless an arrangement has been made with your doctor. Please make sure your general practitioner, hospital or other supplier is willing to provide you with the authorised service at the Makoti Medical Scheme tariff. Please call 0860 00 24 00 for more information or pre-authorisation.

    Visiting your doctor

    When visiting your doctor, please remember to take your Makoti Membership Card and your ID document with you to assist with identifying you as a member of the Scheme. Also make sure you take your health records, such as Baby Clinic card or Family Planning Cards, with when visiting your doctor for the first time.

    Making appointments

    Some doctors and practices prefer you to make appointments for consultations. This will help to:

  • Ensure that you will see the doctor that you need to see
  • Plan your day better
  • Minimise your waiting time
  • Chronic Care Programme

    Beneficiaries are encouraged to join the programme for care for any chronic condition by going to their chosen general practitioner to register their condition. The registration process assists the general practitioner and the patient, to ensure that the patient receives optimal care with minimum administration. The chronic care benefit covers the 27 (Chronic Disease List (CDL)) conditions, including HIV/AIDS. Medication is covered as per the medication formulary and is covered in full once the beneficiary is registered on the chronic care programme by their general practitioner.

    What medicines and laboratory tests are used?

    The Scheme has carefully chosen quality medicines to prevent and treat diseases. It needs to be used in the correct manner and according to the correct dosage and instructions to regain or maintain your health. It is very important to use medicines in the correct dosages, because if they are used incorrectly, this can cause a great deal of harm or even death.

    The majority of these medicines are proven quality generics. If a patient insists on a more expensive alternative, the member will have to pay the additional cost directly to the pharmacy. Medicines commonly requested that are not on the formulary include: vitamins, laxatives and proton pump inhibitors, which are not covered by the Scheme.

    Clinically-appropriate laboratory tests are accessed subject to clinical protocols and pre- authorisation.

    YOUR MEMBERSHIP AND ADMINISTRATION

    Universal Healthcare (Pty) Ltd is responsible for registering the rules and benefits of the Makoti Medical Scheme. The scheme applies underwriting to all new applications, as prescribed by the Medical Schemes Act.

    The following persons are allowed as dependants to the principal member: A spouse or partner, biological children, adopted children, immediate family. Direct family members that are dependent on the member for family care and support are also eligible.

    Cover for children as dependants

    Your children may remain on the Scheme as your dependants, until they become employed or reach the age of 21 years. After reaching the age of 21 years, your children may remain on the Scheme as an adult dependant (and pay adult dependant rates) up to the age of 25 (subject to proof of admission and registration as a student at an accredited institution). Third generation babies (i.e. grandchildren) are not eligible for membership.

    Adding adult dependants

    If you wish to add an adult dependant, underwriting will be done in terms of the Medical Schemes Act.

    How many medical aid schemes can a person belong to?

    You may not belong to more than one medical aid.

    How often can I change my option?

    Once a year, at the end of the year, with the change effective from 1 January. The option change form must reach Makoti by the cut-off date, as specified in the year-end communication.

    Change of option may only be done once a year, effective 1 January of the next year.

    Your membership status

    Please report the following changes to your membership status to the Human Resources department of your company:

    • The birth or legal adoption of a child (within 30 days after birth or adoption)
    • The change of an ID number of a dependant
    • Passing away of a dependant
    • Removal of a dependant
    • Divorce or marriage
    • Addition of dependants
    • Change of address

    Changes in dependant status must be recorded in order for a new card to be issued and to ensure that you pay the correct contributions. You need to check all the details on your membership card to make sure it is correct. Any mistakes must be reported as soon as possible so that a new card with the correct information can be issued to you. Change of status forms can be collected from your Human Resources department or through the Enablemed call centre.

    Your membership card

    Each member is issued with a membership card. Keep your membership card safe and use it well, as it is your passport to quality healthcare services. Please remember that your membership card is only to be used by yourself and your registered dependants. Lending your membership card to unregistered dependants constitutes fraud, which could impact your membership.

    CONTRIBUTIONS

    Contributions to the Makoti Medical Scheme will be deducted from your wages/salary where the Scheme has a contract with your employer or deducted via debit order from your bank account. Contributions are due monthly in advance (or arrears as in agreement with some employer groups).

    Please refer to the contributions section on this website.

    Accounts

    It is the member’s responsibility to ensure that all accounts are submitted to Enablemed as soon as possible. Accounts received four months after the service date will not be paid by the Scheme in terms of the rules of the Scheme and will become the member’s responsibility.

    COMPLAINTS AND DISPUTES

    Your accredited general practitioner

    Members may lodge their complaints telephonically, or in writing, to the Scheme. The Scheme’s dedicated telephone number for dealing with telephonic complaints is 011 208 1000.

    Call centre agents will assist the member immediately, where possible. All unresolved telephone complaints or complaints received in writing will be responded to by the Scheme in writing within 30 days of receipt thereof.

    Should the member not be satisfied with the outcome of the query, then this query or dispute can be escalated to the Fund Manager. E-mail escalations can be sent to escalations@makotihealth.co.za or the call centre agent can transfer the member to the Senior Client Services Manager or, if not available, to the Fund Manager. All escalations will have to be accompanied by supporting evidence of non-delivery.

    Any dispute, which may arise between a member, prospective member, former member or a person claiming by virtue of such membership and the Scheme or an officer of the Scheme, must be referred by the Principal Officer to a disputes committee (appointed by the Board of Trustees) for adjudication.

    On receipt of a request in terms of this rule, the Principal Officer will convene a meeting of the disputes committee by giving not less than 21 days’ notice in writing to the complainant and all the members of the disputes committee, stating the date, time and venue of the meeting and particulars of the dispute. The disputes committee will determine the procedure to be followed.

    The parties to any dispute have the right to be heard at the proceedings, either in person or through a representative. An aggrieved person also has the right to appeal to the Council for Medical Schemes against the decision of the disputes committee. Such appeal must be in the form of an affidavit and directed to Council, and shall be furnished to the Registrar not later than three months after the date on which the decision concerned was made.

    CMS e-mail address for complaints: complaints@medicalschemes.com

     
     

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