Benefits and Contributions

Explore our primary and
comprehensive options.

Benefits and Contributions

Explore our Primary and Comprehensive solutions.

Benefits – 2024 Summary

Primary Option

Overall limit: No limit
General Practitioner Services: Unlimited
Medicines as per formulary acute and chronic: Unlimited

Over-the-counter medicine (OTC):
Limited to R430 per family per annum

Chronic illness screening by General Practitioner:
Annual or when requested

Comprehensive Option

Overall limit: No limit
General Practitioner Services: Unlimited
Medicines as per formulary acute and chronic: Unlimited

Over-the-counter medicine (OTC):
Limited to R459 per family per annum

Chronic illness screening by General Practitioner:
Annual or when requested

All services listed below must be authorised by calling
0860 00 24 00.
In case of an emergency, call
060 982 3823.

Primary Option

Basic pathology and radiology:
Radiology: CXR, suspected fractures of extremities and two obstetric sonars per pregnancy.

Pathology: PAP smear single slide, Glucose, HbA1c, Hb, WCC, Platelets RPR, Blood Group and HIV.

Specialist services:
As per Prescribed Minimum Benefits only in state hospitals.
Hospitalisation:
As per Prescribed Minimum Benefits only in state hospitals.
Emergency stabilisation / casualty in a private hospital:
Medical emergencies only.

Maternity benefit:
In state facilities or private hospitals limited to R28 000 per pregnancy.

Subject to managed care protocols and pre-authorisation.

HIV/AIDS:
Fully covered.

Comprehensive Option

Basic pathology and radiology:
Limited to list of codes.

Subject to pre-authorisation and managed care protocols.

Specialist services:
Subject to managed care protocols, written referral by a GP and pre-authorisation.

Hospitalisation:
Private hospitals.

Subject to managed care protocols and pre-authorisation.

Emergency stabilisation / casualty in a private hospital:
Medical emergencies only.
Maternity benefit:
Fully covered at cost.

Subject to managed care protocols and pre-authorisation.

HIV/AIDS:
Fully covered at cost.

Other Services

Primary Option

Ambulance for medical emergencies:
Fully covered for life threatening emergencies by LifeMed on
0861 086 911.
Clinical psychology:
Prescribed Minimum Benefits in state facility only.

Hearing aids:
Prescribed Minimum Benefits only in state facilities only.

External prostheses/appliances:
Prescribed Minimum Benefits only in state facilities only.

Internal prostheses:
R58 789 per family per year.

Physiotherapy and occupational therapy:
Prescribed Minimum Benefits only in state facilities only.

Optometry:
R1 070 per beneficiary every 24 months including full cost of eye test.

Comprehensive Option

Ambulance for medical emergencies:
Fully covered for life threatening emergencies by LifeMed on
0861 086 911.
Clinical psychology:
8 consultations per family per year.

Hearing aids:
R3 888 per beneficiary every 4 years.

External prostheses/appliances:
R3 850 per family every year.

Internal prostheses:
R58 789 per family per year.

Physiotherapy and occupational therapy:
20 consultations per family per year.

Optometry:
R2 968 per beneficiary every 24 months including full cost of eye test.

Dentistry

Primary Option

Basic prevention, fillings, and extractions:
Fully covered.

Specialised dentistry:
No benefit.

Comprehensive Option

Basic prevention, fillings, and extractions:
Fully covered.

Specialised dentistry:
R4 011 per family per year.
1 set of dentures per beneficiary every 4 years.

Download the full Makoti Medical Scheme Benefits Brochure for more information.

Contribution Tables Effective
1 January 2024

These contributions are the total monthly contribution excluding any employer subsidy.
For members who are liable to pay tax, the SARS Medical Scheme Tax Credit will assist greatly in making the contributions much more affordable.

Primary Option

Income category (R)

0 – 3 430

3 431 – 7 380

7 381 – 10 300

10 301 – 13 740

13 741 – 18 320

18 321+

Principal (R)

355

376

837

897

964

1 034

Adult (R)

355

376

689

725

771

805

Child (R)

230

253

308

331

350

370

Comprehensive Option

Income category (R)

0 – 10 690

10 691 – 14 150

14 151 – 18 770

18 771+

Principal (R)

2 449

2 832

3 053

3 349

Adult (R)

2 110

2 358

2 564

2 870

Child (R)

814

923

991

1 089

What is Excluded?

Please refer to the benefits brochure to see what is not covered by the scheme. You can download the brochure here.

We Pay Third-Party Claims

If you or any of your dependants are involved in a motor vehicle accident, the scheme will have a claim against the third party for medical expenses incurred.

Finding the Right Service Provider for You – The Choice is Yours

Choosing a general practitioner (GP) you are comfortable with is vital. As this is your nominated GP, you are covered to consult, except in the case of an emergency when you will be covered for consultations with other healthcare providers.

 

If your existing GP is not on our provider network, Enablemed can contact the doctor to establish whether they may be interested in contracting with the scheme. Simply reach out to Enablemed and request them to contact your GP.

Makoti Medical Scheme has an extensive national provider footprint

Should you wish to change your GP, you can do so by informing Enablemed and completing the Doctor Choice Form.

We provide dental care

Dental services are arranged through the Dental Information Systems (Pty) Ltd (DENIS) call centre available on 0860 104 925. The dental service provider network can be found by searching https://www.denis.co.za/find-a-network-provider/

Pharmacy Benefit Management

Mediscor is responsible for the Pharmacy Benefit Management for Makoti Medical Scheme and is contracted to all major pharmacy groups as well as to most of the smaller and regional pharmacies.

To view the approved medicines that members may use on the Makoti Medical Scheme medicines formulary, please access the link: www.mediscor.co.za

As a member of Makoti Medical Scheme, all the different aspects of your healthcare cover are carefully managed to ensure that you and your dependants have access to quality, affordable healthcare when you need it.

AN IMPORTANT NOTE FOR PRE-AUTHORISATION

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.

Doctor’s Visit Checklist

When going for your doctor’s appointment, please remember to take:

Your Makoti Membership Card

Your ID Document

Your Health Records

Chronic Care Programme

If you have a chronic condition, please be sure to join the care programme by visiting your chosen general practitioner to register your condition.

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 you are registered on the chronic care programme by your general practitioner.

What medicine am I covered for to treat chronic diseases?

The scheme has carefully chosen quality medicines to prevent and treat chronic diseases.

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

Please download the brochure for more information.

Registering Yourself and Your Dependants

For more information about how to become a member of the scheme, please call the call centre on 011 208 1000.

E

Child dependant rules

Your children may remain on the scheme as your dependants until they become employed or reach the age of 21 years. Child dependants who are studying may remain on the scheme at adult dependant rates up to the age of 25, subject to proof of admission and registration as a student at an accredited institution.

E

Adding adult dependants

For more information about adding an adult dependant, please contact Makoti Medical Scheme on 011 208 1000 or via email at [email protected]. Please note that underwriting will be done according to the Medical Schemes Act.
E

When can I change my option?

You will have the opportunity to change your option at the end of each year. The change will take effect from 1 January. Notify the scheme of your option change by completing the Option Change Form by the cut-off date, as specified in the year-end communication.

Please notify us about any changes that may alter your membership status.

Please report the following changes to your membership status to the scheme directly or to the Human Resources department of your company, if you are a member through your employer:

E

The birth or legal adoption of a child (within 30 days after birth or adoption)

E
The change of an ID number of a dependant
E

Passing away of a dependant

E
Removal of a dependant
E
Divorce or marriage
E
Addition of dependants
E
Change of address

A new membership card will be issued following any of the above changes.

Changes in dependant status must be reported to the scheme in order for a new card to be issued and to ensure that you pay the correct contributions.

Please check that all the details on your membership card are correct. Any changes must be communicated to the scheme as soon as possible so that a new card can be issued to you. The Change of Status Form can be obtained from the Enablemed call centre on 0860 0024 00 or 0860 0024 02 or from your Human Resources department.

Your membership card is your passport to quality healthcare.

Each member is issued a membership card. Keep your membership card safe – this is your passport to quality healthcare.

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.