XHealth Major Medical, Chronic and Day-to-day Benefits

All XHealth products and benefits are subject to Prescribed Minimum Benefits (PMBs), which cover 26 chronic conditions as defined by the Medical Schemes Act 131 of 1998.

An 'Aligned' hospital or Specialist is contracted to XHealth with preferential rates. An 'Any' hospital or Specialist is not contracted with XHealth which might result in payment shortfalls.

A 'State' hospital or Specialist is not contracted to XHealth but accessible to the general public seeking medical services.

Major Medical Benefits (In-hospital Benefits)

This benefit primarily covers hospitalisation, along with some out-of-hospital procedures that can be performed in a doctor's room, day hospital, or outpatient facility. Pre-authorisation is generally required for Major Medical Benefits, including hospitalisation, day hospital admissions, specialised procedures/treatment, and MRI and CT scans. Failure to obtain pre-authorisation (except in medical emergencies) may result in the Scheme covering only 70% of the accounts at agreed negotiated rates.

Here’s how Major Medical Benefits apply to each product:

NormX:

• Hospital Provider: Members can choose between Any hospital or Aligned hospitals. If Aligned hospitals are chosen but not used, a 30% co-payment applies to the hospital account, except for emergencies.
• Overall Annual Limit: No overall annual limit applies for hospitalisation.
• Specialist Cover: Accounts for Aligned specialists are covered in full, while other specialists are covered up to 100% of the XHealth Rate.
• Co-payments: A standard R2,100 co-payment per authorisation applies to hospital admissions, except for motor vehicle accidents, maternity confinements, and emergency treatment. This co-payment also applies to PMBs, excluding emergencies. Additional co-payments may apply for specialised scans (R3,000 per scan), dental benefits, and certain specialised procedures/treatment (e.g., R1,920 for day hospital procedures, R3,840 for acute hospital procedures).
• Prosthesis: Internal prostheses (excluding cochlear implants) are covered up to R49,000 per beneficiary per event, with a maximum of two events per year.
• Intraocular lenses are covered up to R6,000 per beneficiary per event, with a maximum of two events per year.
• External prostheses are limited to R28,000 per family.
• Pre-authorisation is required for prosthesis benefits.
• Oncology: A limit of R300,000 per beneficiary per year applies, after which a 20% co-payment is applied. XHealth reference pricing may apply to chemotherapy and adjuvant medication.
• Mental Health/Rehabilitation: Mental health benefits are limited to R45,000 per beneficiary. Medical rehabilitation, private nursing, hospice, and step-down facilities have a combined limit of R65,000 per family, subject to case management.

GrowX:

• Hospital Provider: Hospitalisation is covered at the GrowX Network of private hospitals. If GrowX Network hospitals are not used, a 30% co-payment applies to the hospital account, except for emergencies. Certain procedures/treatment are only covered in day facilities; a 30% co-payment applies if these are not used.
• Overall Annual Limit: No overall annual limit applies for hospitalisation.
• Specialist Cover: Accounts for Aligned specialists are covered in full; other specialists are covered up to 100% of the XHealth Rate.
• Co-payments: A standard R1,920 co-payment per authorisation applies, with exceptions for motor vehicle accidents, maternity confinements, and emergency treatment. Additional co-payments may apply for specialised scans and certain specialised procedures/treatment (e.g., R3,840 if performed in an acute or day hospital). Specialised scans like MRI and CT scans are subject to a R3,200 co-payment per scan and pre-authorisation.
• Prosthesis: Internal prostheses (excluding cochlear implants and joint replacements) are covered up to R42,000 per beneficiary per event, with a maximum of two events per year.
• Intraocular lenses are covered up to R6,000 per beneficiary per event, with a maximum of two events per year.
• Joint replacements, including knee and hip surgery, are limited to Prescribed Minimum Benefits at State facilities.
• External prostheses are limited to R27,000 per family.
• Pre-authorisation is required for prosthesis benefits.
• Oncology: A limit of R200,000 per beneficiary per year applies, after which a 20% co-payment is applied. Members must obtain oncology treatment and medication from the GrowX Network of oncologists. Reference pricing may apply to chemotherapy and adjuvant medication.
• Mental Health/Rehabilitation: Mental health benefits (psychiatry, psychology, drug/alcohol rehabilitation) are limited to Prescribed Minimum Benefits. Medical rehabilitation, private nursing, hospice, and step-down facilities have a combined limit of R58,000 per family, subject to case management.
• Trauma Benefit: Covers certain day-to-day claims as part of recovery from specific traumatic events, such as burns, paraplegia, quadriplegia, conditions from near-drowning, poisoning, severe allergic reactions, and external/internal head injuries (if ICU stay of 5+ days occurred). Benefits, including GP/specialist visits, private nursing, radiology, pathology, psychiatric consultations, wound care, plastic surgery, and medication, are covered for 18 months following the traumatic event, subject to authorisation and a doctor's motivation.

GearX:

• Hospital Provider: Members can choose between Any hospital or Aligned hospitals. If Aligned hospitals are chosen but not used, a 30% co-payment applies to the hospital account, except for emergencies.
• Overall Annual Limit: No overall annual limit applies for hospitalisation.
• Specialist Cover: Accounts for Aligned specialists are covered in full; other specialists are covered up to 200% of the XHealth Rate.
• Co-payments: Co-payments may apply to specialised scans, dental benefits, and certain specialised procedures/treatment. Anaesthetist costs for gastroscopies and colonoscopies are covered up to R1,500, subject to pre-authorisation. Specialised scans like MRI and CT scans are subject to a R2,000 co-payment per scan and pre-authorisation.
• Prosthesis: Internal prostheses (excluding cochlear implants and intraocular lenses) are covered up to R88,000 per beneficiary per event, with a maximum of two events per year.
• Cochlear implants are covered up to R220,000 per beneficiary, with a maximum of one event per year.
• Intraocular lenses are covered up to R9,900 per beneficiary per event, with a maximum of two events per year.
• External prostheses are limited to R30,000 per family.
• Pre-authorisation is required for prosthesis benefits.
• Oncology: A limit of R500,000 per beneficiary per year applies, after which a 20% co-payment is applied. XHealth reference pricing applies to chemotherapy and adjuvant medication. If State is chosen as the chronic provider, oncology treatment must be obtained from an oncologist authorised by XHealth.
• Dental Health/Rehabilitation: Mental health benefits are limited to R48,000 per beneficiary. Medical rehabilitation, private nursing, hospice, and step-down facilities have a combined limit of R72,000 per family, subject to case management.
• Trauma Benefit: Similar coverage to the GrowX product for burns, paraplegia, quadriplegia, and conditions from near-drowning, poisoning, severe allergic reactions, and external/internal head injuries (if ICU stay of 5+ days occurred). Benefits are covered for 18 months following the traumatic event, subject to authorisation and doctor's motivation.

MotiveX:

• Hospital Provider: Members can choose between Any hospital or Aligned hospitals. If Aligned hospitals are chosen but not used, a 30% co-payment applies to the hospital account, except for emergencies.
• Overall Annual Limit: No overall annual limit applies for hospitalisation.
• Specialist Cover: Accounts for Aligned specialists are covered in full; other specialists are covered up to 200% of the XHealth Rate.
• Co-payments: Co-payments may apply to specialised scans, dental benefits, and certain specialised procedures/treatment. Anaesthetist costs for gastroscopies and colonoscopies are covered up to R1,800, subject to pre-authorisation. Specialised scans like MRI and CT scans are subject to a R2,900 co-payment per scan and pre-authorisation.
• Prosthesis: Internal prostheses (excluding cochlear implants and intraocular lenses) are covered up to R64,000 per beneficiary per event, with a maximum of two events per year.
• Cochlear implants are covered up to R214,000 per beneficiary, with a maximum of one event per year.
• Intraocular lenses are covered up to R8,000 per beneficiary per event, with a maximum of two events per year.
• External prostheses are limited to R29,000 per family.
• Pre-authorisation is required for prosthesis benefits.
• Oncology: A limit of R400,000 per beneficiary per year applies, after which a 20% co-payment is applied. XHealth reference pricing applies to chemotherapy and adjuvant medication. If State is chosen as the chronic provider, oncology treatment must be obtained from an oncologist authorised by XHealth.
• Mental Health/Rehabilitation: Mental health benefits are limited to R48,000 per beneficiary. Medical rehabilitation, private nursing, hospice, and step-down facilities have a combined limit of R67,000 per family, subject to case management.
• Trauma Benefit: Similar coverage to the GrowX product for burns, paraplegia, quadriplegia, and conditions from near-drowning, poisoning, severe allergic reactions, and external/internal head injuries (if ICU stay of 5+ days occurred). Benefits are covered for 18 months following the traumatic event, subject to authorisation and doctor's motivation.

OneX:

• Hospital Provider: Members can choose to get treatment from Any hospital, the OneX Network of private hospitals, or Connect Network hospitals. If OneX Network or Connect Network hospitals are chosen but not used, a 30% co-payment applies to the hospital account, except for emergencies.
• Overall Annual Limit: No overall annual limit applies for hospitalisation.
• Specialist Cover: Accounts for specialists are covered up to 100% of the XHealth Rate.
• Co-payments: A 30% co-payment applies to all claims relating to treatment and hospital accounts if pre-authorisation is not obtained in time for non-emergency admissions.
• Prosthesis: Internal and external prostheses are limited to Prescribed Minimum Benefits at State facilities.
• Oncology: If Connect Network hospitals are chosen, oncology benefits are limited to Prescribed Minimum Benefits at Connect Network hospitals. If OneX Network hospitals or Any hospital are chosen, benefits are limited to Prescribed Minimum Benefits at State facilities.
• Mental Health/Rehabilitation: Mental health benefits (psychiatry, psychology, drug/alcohol rehabilitation) are limited to Prescribed Minimum Benefits at State facilities. Medical rehabilitation and step-down facilities have a combined limit of R16,700 per beneficiary, subject to case management. Private nursing and hospice are not covered.

PinnacleX:

• Hospital Provider: Members have unlimited private hospital cover from Any provider.
• Overall Annual Limit: No overall annual limit applies for hospitalisation.
• Specialist Cover: Accounts for Aligned specialists are covered in full; other specialists are covered up to 300% of the XHealth Rate.
• Co-payments: A co-payment may apply to specialised scans. Anaesthetist costs for gastroscopies and colonoscopies are covered up to R1,600, subject to pre-authorisation. Specialised scans like MRI and CT scans are subject to a R2,900 co-payment per scan and pre-authorisation.
• Prosthesis: Internal prostheses (excluding cochlear implants and intraocular lenses) are covered up to R88,000 per beneficiary per event, with a maximum of two events per year.
• Cochlear implants are covered up to R230,000 per beneficiary, with a maximum of one event per year.
• Intraocular lenses are covered up to R9,000 per beneficiary per event, with a maximum of two events per year.
• External prostheses are limited to R30,000 per family.
• Pre-authorisation is required for prosthesis benefits.
• Oncology: No annual limit applies for oncology benefits. XHealth reference pricing applies to chemotherapy and adjuvant medication.
• Mental Health/Rehabilitation: Mental health benefits are limited to R48,000 per beneficiary. Medical rehabilitation, private nursing, hospice, and step-down facilities have a combined limit of R72,000 per family, subject to case management.
• Trauma Benefit: Similar coverage to the GrowX product for burns, paraplegia, quadriplegia, and conditions from near-drowning, poisoning, severe allergic reactions, and external/internal head injuries (if ICU stay of 5+ days occurred). Benefits are covered for 18 months following the traumatic event, subject to authorisation and doctor's motivation.

Chronic Benefits

Chronic Benefits ensure cover for specific life-threatening conditions requiring ongoing treatment, such as diabetes and heart disease. These benefits are subject to registration on the Chronic Management Programme and approval by the Scheme. The choice of chronic provider determines how and where treatment, prescriptions, and medication are obtained.

NormX:

• Cover: Covers 26 conditions as per the Prescribed Minimum Benefits (PMB) Chronic Disease List.

Provider Choice:

• Any: Members can obtain chronic prescriptions and medication from any provider, subject to a Basic formulary. Co-payments apply for medication outside the preferred list or above the XHealth Reference Price (e.g., 15% for non-preferred medication). A dispensing fee co-payment may apply for non-contracted pharmacies.
• Aligned: Chronic prescriptions must be from an Aligned GP or Aligned specialist, and chronic medication from Medipost, subject to a Core formulary. If non-Aligned providers are used, the Scheme pays 50% of the XHealth Rate for consultations or 50% of the formulary price for medication.
• State: Chronic treatment, prescriptions, and medication must be obtained from designated State facilities, subject to a State formulary. If State facilities cannot provide PMB chronic medicine, members may obtain it from an OneX Primary Care Network doctor, subject to a Fixed formulary and Scheme approval.
• Registration: Requires the treating doctor or pharmacist to call the Scheme, providing membership details, diagnosis code (ICD-10), and practice number.
• Non-approved Benefits: If approval for chronic benefits is not obtained, treatment may be paid from XSaver, if available, otherwise it is self-funded.

GrowX:

• Cover: Covers 26 conditions as per the PMB Chronic Disease List.
• Provider Choice: Chronic treatment, prescriptions, and medication must be obtained from State facilities, subject to a State formulary.
• Registration: Requires contacting the Scheme for a State chronic application form, which the State doctor completes. The form and supporting documents are then emailed to the Scheme.
• Non-approved Benefits: If approval for chronic benefits is not obtained, treatment may be paid from XSaver, if available, otherwise it is self-funded.

GearX:

• Cover: Covers 62 conditions: 26 PMB conditions with no annual limit, and 36 additional conditions with a limit of R13,000 per family per year.

Provider Choice:

• Any: Members can obtain chronic prescriptions and medication from any provider, subject to an Extended formulary. Co-payments apply for medication outside the preferred list or above the XHealth Reference Price (e.g., 5% for non-preferred medication). A dispensing fee co-payment may apply for non-contracted pharmacies.
• Aligned: Chronic prescriptions must be from an Aligned GP or Aligned specialist, and chronic medication from Medipost, subject to a Core formulary. Similar co-payment rules as NormX for non-Aligned providers or non-Medipost medication.
• State: Chronic treatment, prescriptions, and medication must be obtained from State facilities, subject to a State formulary. If State facilities cannot provide PMB chronic medicine, members may obtain it from an OneX Primary Care Network doctor, subject to a Fixed formulary and Scheme approval.
• Registration: Similar telephonic registration process as NormX.
• Non-approved Benefits: If approval for chronic benefits is not obtained, treatment may be paid from Day-to-day Benefits, if available, otherwise it is self-funded.

MotiveX:

• Cover: Covers 32 conditions: 26 PMB conditions with no annual limit, and 6 additional conditions with a limit of R13,100 per family per year.

Provider Choice:

• Any: Members can obtain chronic prescriptions and medication from any provider, subject to a Standard formulary. Co-payments apply for medication outside the preferred list or above the XHealth Reference Price (e.g., 10% for non-preferred medication). A dispensing fee co-payment may apply for non-contracted pharmacies.
• Aligned: Chronic prescriptions must be from an Aligned GP or Aligned specialist, and chronic medication from Medipost, subject to a Core formulary. Similar co-payment rules as NormX for non-Aligned providers or non-Medipost medication.
• State: Chronic treatment, prescriptions, and medication must be obtained from State facilities, subject to a State formulary. If State facilities cannot provide PMB chronic medicine, members may obtain it from an OneX Primary Care Network doctor, subject to a Fixed formulary and Scheme approval.
• Registration: Similar telephonic registration process as NormX.
• Non-approved Benefits: If approval for chronic benefits is not obtained, treatment may be paid from Savings or XSaver, if available, otherwise it is self-funded.

OneX:

• Cover: Covers 26 conditions as per the PMB Chronic Disease List.

Provider Choice:

• If Connect Network hospitals are chosen, benefits are only available at State facilities.
• If OneX Network hospitals or Any hospital are chosen, benefits are only available from the OneX Primary Care Network or OneX Active Network, with chronic medication from Medipost, according to a Fixed formulary. Medicine not on the formulary will not be paid.
• Registration: Requires the GP to obtain approval from XHealth telephonically, then contact Medipost for medication delivery. For State providers, a State chronic application form needs to be completed and emailed.
• Non-approved Benefits: If approval for chronic benefits is not obtained, treatment may be paid from XSaver, if available, otherwise it is self-funded.

PinnacleX:

• Cover: Covers 62 conditions: 26 PMB conditions with no annual limit, and 36 additional conditions which accumulate to the overall day-to-day limit of R33,000 per beneficiary.
• Provider Choice: Members have the freedom of choice to obtain chronic prescriptions and medication from any provider, subject to a Comprehensive formulary.
• Registration: Requires the treating doctor or pharmacist to call the Scheme, providing membership details, diagnosis code (ICD-10), and practice number.
• Non-approved Benefits: If approval for chronic benefits is not obtained, treatment may be paid from Day-to-day Benefits, if available, otherwise it is self-funded.

Day-to-Day Benefits

Day-to-Day Benefits cover routine medical expenses such as doctor's visits and prescribed medication.

NormX:

• General Rule: Day-to-day benefits are subject to fund availability in XSaver, a voluntary savings account.
• Covered services: Includes acupuncture, homeopathy, audiology, occupational and speech therapy, chiropractors, dieticians, biokinetics, orthoptists, osteopathy, audiometry, chiropody, physiotherapy, podiatry, mental health (psychiatry and psychology), basic and specialised dentistry, external medical and surgical appliances, general practitioners, specialists, optical and optometry, pathology, radiology, prescribed medication, and over-the-counter medication. All these benefits are paid from the XSaver savings account.
• MRI and CT scans: Covered from Major Medical Benefit, subject to pre-authorisation and a R3,200 co-payment per scan.

GrowX:

• General Rule: Day-to-day benefits are subject to fund availability in XSaver, a voluntary savings account.
• Covered services: Similar to NormX, most services like acupuncture, homeopathy, mental health, dentistry, external medical appliances, specialists, optical, pathology, radiology, and medication. All these benefits are paid from the XSaver savings account provided funds are availble.
• GP Virtual Consultations: Includes 2 free virtual consultations per beneficiary per year from the GP Virtual Consultation Network (including Hello Doctor), which covers scripting of medication up to schedule 4.
• Sports Injury Benefit: Covers 2 Physiotherapist or Biokineticist consultations per beneficiary, up to a limit of R1,120 per year, subject to pre-authorisation and paid at the XHealth Rate.
• MRI and CT scans: Covered from Major Medical Benefit, subject to pre-authorisation and a R3,200 co-payment per scan.

GearX:

• General Rule: 25% of the total contribution is allocated to cover day-to-day expenses, known as Savings. If Savings are insufficient, members enter a self-funding gap up to a defined Threshold. Once the Threshold is reached, claims are paid by the Scheme from Extended Cover at the XHealth Rate, subject to sub-limits.
• Annual Threshold levels: R33,400 for a member, R29,000 per adult dependent, and R9,600 per child (maximum 3 children).
• Provider: Any or Aligned (Aligned GPs must be used for GP consultations if Aligned chronic provider chosen).

Covered services & Limits:

• Acupuncture, homeopathy, etc., basic dentistry, pathology, radiology: Unlimited within the General Rule provisions.
• Mental health (psychiatry and psychology): R25,200 per family.
• Specialised dentistry (bridges or crowns): R17,300 per beneficiary, R44,900 per family. Both in-hospital and out-of-hospital dental specialist accounts accumulate towards this limit. Anaesthetist and dental specialist accounts for impacted wisdom teeth extractions in doctors' rooms are covered from Major Medical Benefit at 100% of MMS Rate, subject to R1,750 co-payment and pre-authorisation.
• External medical and surgical appliances: R31,200 per family, with a R9,420 sub-limit per family for hearing aids, subject to pre-authorisation.
• General practitioners: 100% of MMS Rate for Any or State providers. For Aligned providers, 100% of MMS Rate for Aligned GPs and 70% for non-Aligned GPs.
• Specialists: 100% of MMS Rate.
• Optical and optometry: Overall limit of R5,300 per beneficiary, with a frame sub-limit of R2,890.
• MRI and CT scans: Covered from Major Medical Benefit, subject to pre-authorisation and a R2,900 co-payment per scan.

MotiveX:

• General Rule: 10% of the total contribution is allocated to Savings for day-to-day expenses. Benefits are subject to funds available in Savings. Members can opt for additional savings through XSaver.
• Provider: Any.
• Covered services: Most services, including acupuncture, homeopathy, mental health (psychiatry and psychology), basic and specialised dentistry (excluding impacted wisdom teeth which are covered under Major Medical Benefit), external medical and surgical appliances, general practitioners, specialists, optical and optometry, pathology, radiology, prescribed medication, and over-the-counter medication, are all subject to Savings if available.
• MRI and CT scans: Covered from Major Medical Benefit, subject to pre-authorisation and a R2,900 co-payment per scan.

OneX:

• General Rule: If Connect Network hospitals are chosen, benefits are available from State facilities. If OneX Network hospitals or Any hospital are chosen, benefits are available from the OneX Primary Care Network or OneX Active Network, subject to network rules and protocols. Additional cover can be obtained via XSaver.
• Provider: OneX Primary Care Network, OneX Active Network, or State facilities.

Covered services & Limits:

• Acupuncture, homeopathy, etc., mental health: Limited to Prescribed Minimum Benefits at State facilities.
• Basic Dentistry: Examinations, fillings, and x-rays as per tariff codes. One dental consultation per year per beneficiary is covered. Pre-authorisation is required for more than 4 fillings or 4 extractions. Specialised dentistry (bridges or crowns) is not covered.
• External medical and surgical appliances: Not covered.
• General Practitioners: No limit on network GP visits, but all visits from the 11th visit onwards must be pre-authorised. Includes 3 virtual doctor consultations per beneficiary per year from the GP Virtual Consultation Network (e.g., HeyDoc).
• Out-of-network GP, casualty, or after-hours visits: 1 visit per beneficiary per year (maximum 2 visits per family per year), subject to authorisation (within 72 hours of consultation) and a R110 co-payment per visit. Failure to authorise results in a 30% co-payment.
• Specialists: 2 visits per family per year, limited to R1,350 per visit and a maximum of R2,700 per family per year, covered at 100% of MMS Rate. Subject to referral and pre-authorisation. Psychologists and psychiatrists are limited to PMBs at State facilities. Physiotherapy is included in the specialist limit.
• Optical and optometry: 1 eye test and 1 pair of clear standard or bi-focal lenses with a standard frame per beneficiary every 2 years, if refraction measurement is more than 0.5. Tinted lenses and contact lenses are not covered.
• Pathology and Radiology (basic): Specific lists of blood tests, urine sample tests, and black and white x-rays are covered if requested by a network GP and within approved lists.
• MRI and CT scans: If Connect Network hospitals are chosen, MRI and CT scans are limited to Prescribed Minimum Benefits at Connect Network hospitals; other specialised scans are subject to PMBs at State facilities. If OneX Network hospitals or Any hospital are chosen, all scans are limited to Prescribed Minimum Benefits at State facilities.
• Prescribed medication: Subject to a prescribed formulary.

PinnacleX:

• General Rule: Benefits are paid at 100% of the XHealth Rate, subject to annual sub-limits and an overall day-to-day limit of R33,000 per beneficiary. There is no Savings component; members can add XSaver.
• Provider: Any provider.

Covered services & Limits:

• Acupuncture, homeopathy, etc.: R9,000 per family, subject to the R33,000 overall day-to-day limit per beneficiary.
• Mental health (psychiatry and psychology): R28,000 per family, subject to the R33,000 overall day-to-day limit per beneficiary.
• Basic dentistry: Subject to the R33,000 overall day-to-day limit per beneficiary.
• Specialised dentistry (bridges or crowns): R22,000 per beneficiary, R47,000 per family, subject to the R33,000 overall day-to-day limit per beneficiary. Both in-hospital and out-of-hospital dental specialist accounts accumulate towards this limit. Anaesthetist and dental specialist accounts for impacted wisdom teeth extractions in doctors' rooms are covered from Major Medical Benefit at 100% of MMS Rate, subject to pre-authorisation.
• External medical and surgical appliances: R38,400 per family, with a R22,200 sub-limit for hearing aids, subject to the R33,000 overall day-to-day limit per beneficiary.
• General practitioners, specialists, optical and optometry, pathology, radiology: All subject to the R33,000 overall day-to-day limit per beneficiary.
• Optical and optometry: Overall limit b
• Prescribed medication: R25,000 per beneficiary, R42,000 per family, subject to the R33,000 overall day-to-day limit per beneficiary.
• Over-the-counter medication: Not covered.
• MRI and CT scans: Cob

For all products, you can obtain authorisation and information via the XHealth App, web chat, email (assist@xhealth.co.za), or by calling 0860 55 55 55.