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Benefit Options and Exclusions

  Member Brochure in PDF format Download the Member Brochure

Makoti offers two benefit options. You need to choose the option that:

  • You can afford, and that
  • Suits your healthcare needs

Option 1: Primary Option

General Practitioner Services, Medication and Statutory Prescribed Minimum Benefits. All benefits are subject to pre-authorisation and include:

  • Unlimited primary health care from your chosen general practitioner
  • Medication as per formulary – acute and chronic
  • Basic pathology and radiology as authorised (Radiology: CXR – suspected fractures of extremities and two obstetric sonars per pregnancy) (Pathology: PAP smear single slide, Glucose, Hb, WCC, Platelets RPR, Blood Group)
  • Ambulance services for medical emergencies. Lifemed ambulance 0861 086 911
  • Optometry and Primary Care Dentistry benefits are provided by accredited providers, subject to authorisation and limits

Statutory Prescribed Minimum Benefits as authorised, in respect of the relevant health services as described in terms of section 67(1)(g) of the Act Accessed in State Hospitals.

Experienced risk managers review all hospital admissions to optimise care and expenditure.

Optometry

Spectacles must be obtained from an accredited optometrist, as authorised via the call centre 0860 00 24 00, necessary for correcting significant visual impairment problems.

Limitations:

Lenses: One set of lenses per beneficiary every 24 months
Frames: One frame per beneficiary every 24 months

The cost of single lenses is fully covered subject to the following conditions:

  • The refraction error must be equal to, or more than 0.5 dioptre
  • The total cost including testing and spectacle is limited to R786.00 per beneficiary per 24 months

The scheme is not liable for the following:

  • Multi focal lenses are not covered
  • Contact lenses are not covered
  • Replacement of lost spectacles is not covered

Dentistry

All dentistry must be provided by an accredited dentist or dental therapist, after the dentist has obtained authorisation via: Dental Information Systems (Pty) Ltd, call no. at 0860 033 647

The following conservative dentistry is fully covered within managed care protocols:

  • Consultations
  • Fillings: pre-authorisation applies
  • Extractions: pre-authorisation applies
  • Prevention: pre-authorisation applies

IN CASE OF AN EMERGENCY, contact Enablemed National Call Line as soon as possible at 0860 00 24 00.

Option 2: Comprehensive Option

All benefits are subject to pre-authorisation and include:

  • Unlimited primary health care from your chosen general practitioner
  • Medication as per formulary – acute and chronic
  • Hospitalisation including step down care as appropriate – subject to pre-authorisation and PMB’s
  • Specialist services – subject to pre-authorisation (items excluded Items Excluded);
  • Pathology and Radiology services are available provided they are pre-authorised subject to standard treatment protocols
  • Ambulance services for medical emergencies Lifemed ambulance 0861 086 911
  • Statutory Prescribed Minimum Benefits as authorised, in respect of the relevant health services as described in terms of Section 67(1)(g) of the Act. The purpose in specifying Prescribed Minimum Benefits is to avoid incidents where individuals lose their medical scheme cover in the event of serious illness

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

  • Optometry
  • Dentistry
  • Other services

Optometry

Spectacles must be obtained from an accredited optometrist, as authorised via the call centre 0860 00 24 00, necessary for correcting significant visual impairment problems.

Limitations:

Lenses: One set of lenses per beneficiary every 24 months
Frames: One set of frames per beneficiary every 24 months

The cost of single lenses is fully covered subject to the following conditions:

  • The refraction error must be equal to, or more than 0.5 dioptre
  • The total cost including testing and spectacle is limited to R2 118.00 per beneficiary per 24 months
  • Multi focal and contact lenses are covered within the limit

The scheme is not liable for the following

  • Replacement of lost spectacles is not covered

Dentistry

All dentistry must be provided by an accredited dentist or dental therapist, after the dentist has obtained authorisation via: Dental Information Systems (Pty) Ltd, call no. at 0860 033 647

The following conservative dentistry is fully covered within managed care protocols:

  • Consultations
  • Fillings: pre-authorisation applies
  • Extractions: pre-authorisation applies
  • Prevention: pre-authorisation applies
  • Dentures are limited to one set of plastic dentures every four years

Specialised dentistry is subject to an annual limit of R2 862 per family (includes root canal and all periodontal treatment).

Specialist Services

All specialist services must be pre-authorised via the Enablemed National Call line 0860 00 24 00.

Other Services

  • Clinical Psychology Limited to 8 consultations per family per year and subject to pre-authorisation.
  • Hearing Aids Limited to R2 774 per beneficiary every 4 years and subject to pre-authorisation.
  • External Prosthesis A maximum of R2 747 per member per annum for external orthopaedic prosthesis and subject to pre-authorisation.
  • Physiotherapy and Occupational Therapy A maximum of 20 treatments per family per annum and subject to preauthorisation.
  • 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
  • Podiatry, acupuncture, homeopathy, naturopathy and chiropractic are not covered
  • Non emergency visits to out-patient facilities at hospitals/casualties

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

You should carefully consider who you would like to have as your regular doctor and make sure that he or she is easily accessible to you. Enablemed will conclude an agreement with him or her to provide you with the services as covered by the scheme.

NB: It is important to understand that this will then be the only general practitioner you will be able to consult (except in emergencies). We believe that staying with one provider has many advantages; you will build a relationship of trust with your doctor and he or she will get to know you and your particular needs better. This will also eliminate the possibility of conflicting treatments and medication that can result from seeing different doctors.

If you wish to change your regular provider, you can do so through your Human Resources department by completing a New Doctor Choice Form. Dental service providers must be arranged through the Dental Call Centre on 0860 104 925.

MANAGED HEALTHCARE

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

Managed healthcare has the following aims:

  • To provide you and your dependants with high-quality healthcare protocols that were developed by the scheme and that need to be followed to access your benefits.
  • To keep healthcare affordable to as many people as possible.

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, unless an arrangement has been made with your doctor. Please make sure your general practitioner, hospital or other healthcare provider is willing to provide you with the authorised service at the Makoti Medical Scheme tariff. For assistance in this regard, please call 0860 002 400.

Visiting your doctor

When visiting your doctor, please take your Makoti Membership Card and your ID document with you, for identification. Also take along your health records such as Baby Clinic or Family Planning Cards, to provide your doctor with a clear medical history.

Making appointments

Some doctors and practices see patients by appointment only. Scheduling your appointment in advance will also help you to ensure that you are able to consult with your doctor of choice and minimise waiting time.

Chronic Care Programme

We encourage you to join our Chronic Care Programme for care of any chronic illness by visiting your chosen doctor to register your condition. The registration process assists both your doctor and you as the patient to ensure that you receive optimal care with minimum administration. Our Chronic Care Programme covers all 27 chronic conditions that are on the Chronic Disease List (CDL) of the Council for Medical Schemes, including HIV/AIDS. Medication is covered as per the formulary. You will enjoy full cover as soon as your doctor officially registers you on the Chronic Care Programme.

What medicines and laboratory tests are used?

Makoti has carefully selected a list of quality medicines for the treatment and prevention of diseases. To maintain your health, it is of the utmost importance to use all medicines exactly as prescribed. Irresponsible use of medication poses a number of health threats that can even result in death. The majority of the medicines on our list are proven quality generics. Should you wish to use a more costly alternative, you will be responsible for paying the additional cost directly to your pharmacy. Medication commonly requested that is not on the formulary, includes vitamins, laxatives, proton pump inhibitors and over-the-counter (OTC) medicines. Clinically appropriate laboratory tests are accessed subject to protocol 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.

A spouse or partner, biological children, adopted children and immediate family members that are dependent on the member for family care and support are eligible for cover.

Cover for children as dependants

Your children may remain on the Makoti Medical Scheme as your dependants until they become employed or reach the age of 21 years.

As soon as your children reach 21 years of age, their status must be converted to that of adult dependant.

Adding adult dependants

If you wish to add adult dependants, underwriting will be done according to 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?

You may change your option once a year, at the end of the year. Any changes will become effective from 1 January of the next year. To do so, you must complete an Option Change Form that must reach Makoti by no later than 30 November.

Your membership status and personal details

Please report any changes regarding your membership or your personal information to your Human Resource department as soon as they occur.
Changes can include:

  • The birth or legal adoption of a child.
  • The new ID number of a dependant.
  • Passing away of a dependant.
  • Removal of a dependant from your medical aid.
  • Divorce.
  • Addition of dependants.
  • Change of option (this may only be done once a year by 30 November, to be effective from 1 January).
  • Change of address.

Changes in dependant status must be recorded for a new card to be issued. To avoid delays in payment of any claims, you need to check all the details on your membership card and make sure they are correct. Any mistakes must be reported as soon as possible so that a new card can be issued to you. Change of status forms can be collected from your human resources department.

Your membership card

Each member is issued with a membership card. If your membership card is lost or stolen you can request a new card by sending an e-mail to membership@universal.co.za.

CONTRIBUTIONS

Your contribution to the Makoti Medical Scheme is deducted from your wages/salary. Your employer pays this contribution to the scheme each month in advance.

Please refer to the contributions section on this website.

Accounts

It is your responsibility as the member to ensure that Enablemed receives all accounts from Healthcare providers immediately. Accounts that are received four months after the service date will not be paid by the scheme and will be for your own account.

COMPLAINTS AND DISPUTES

Your accredited general practitioner

You may lodge any complaints with the scheme in writing (makoti@universal.co.za) or telephonically (011 208 1000) to the scheme’s telephone line.

Our Call Centre agents will endeavour to assist you immediately. All unresolved telephonic or written complaints will be responded to in writing, within 30 days of receipt.

Any dispute that may arise between a member, prospective member, former member or a person claiming by virtue of such member and the scheme or an officer of the scheme, must be referred by the Principal Officer to the Disputes Committee (appointed by the Board of Trustees) for adjudication. On receipt of a request in terms of this rule, the Principal Officer must 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 may 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 has the right to appeal to the Council for Medical Schemes (CMS) against the decision of the Disputes Committee. Such an appeal must be in the form of an affidavit and directed to the Council and should be lodged with the Registrar no later than three months after the date on which the decision was made. The CMS may be contacted telephonically on 0861 123 267 or via email at complaints@medicalschemes.com.

 
 

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