Benefits: Managed Care Programmes

In addition to the services and procedures covered under Hospital and Trauma Benefits, you will also receive assistance, support and education on your condition if you register on the following Managed Care Programmes:

 

NEW! Weight Management Programme

Being overweight, and especially being obese, substantially increases your risk of chronic conditions, including hypertension, abnormal cholesterol levels, type 2 diabetes, coronary artery disease, stroke, gallbladder disease, osteoarthritis, sleep apnea and respiratory problems, as well as cancers of the endometrium, breast, prostate, and colon.

Obesity is a complex disease that is dependent on many factors, including a person’s genetics and lifestyle. It is important to implement a longer-term, sustainable plan that will lead to a healthier lifestyle, which is what the Scheme’s Weight Management Programme aims to help members do.

WHAT DOES THE WEIGHT MANAGEMENT PROGRAMME ENTAIL?

Qualifying members will be referred to a biokineticist, where a full assessment will be undertaken to determine his or her suitability for the programme. This will include:

  • an online lifestyle questionnaire;
  • validated biometric testing, including blood pressure, cholesterol, blood sugar levels, height and weight (BMI); and
  • a fitness assessment.

At the end of the assessment the member will receive a comprehensive health status report with tailored recommendations for health improvement.

Suitable candidates will be enrolled on a 12-week programme that includes weekly group-exercise sessions, one-on-one consultations with a biokineticist, and referral to a dietician and psychologist, if necessary.

HOW CAN YOU ACCESS THE BENEFIT?

If you think that you may qualify and you are interested in this programme, contact Member Care for more information, or to confirm whether you qualify:

Call 0860 106 155 or
Email membercare@medscheme.co.za

You will typically qualify to take part in this Programme if:

  • BMI*: Your body mass index (BMI) is 30 or more, or
  • WAIST CIRCUMFERENCE: You are a man with a waist circumference of 102 cm or more, or a woman with a waist circumference of 88 cm or more, or
  • MOTIVATED CASE: Your general practitioner or a BASA biokineticist motivates your case (for example, if your BMI is between 25 and 30 and you have diabetes and comorbidities).

* To calculate your BMI, divide your weight in kilograms (kg) by your height in metres (m), and then divide the answer by your height again. This will give you your BMI in kg/m2.

Diabetes Management Programme

The Scheme’s Diabetes Management programme helps members with diabetes better understand this long-term condition and empowers them to make the right decisions to stay healthy.

As most diabetics have at least one other chronic condition, the programme offers a personalised care plan to ensure that your specific needs are taken into account. The care plan will provide cover for the tests required for the management of diabetes as well as your other chronic conditions. It offers access to specialised diabetes doctors, dieticians, podiatrists and diabetic educators to allow you to effectively manage your diabetes.

In addition, you will have access to a dedicated Health Coach to answer any questions you may have, and you will also enjoy online assistance through HealthCloud.

HOW TO ACCESS THE PROGRAMME

For more information, or to register on this programme:

Call 0860 100 080, or

Email membercare@medscheme.co.za

The Scheme believes that managing diabetes should be based on the principles of patient-centred care and must embrace a personalised approach. When you register for diabetes care, we take your other medical needs into account , including any other chronic conditions you may have. In addition, we continue to work with your doctor who looks after your chronic conditions, to provide co-ordinated, quality care.

Mental Health Programme

The Mental Health Programme is aimed at beneficiaries with certain mental health conditions and substance abuse disorders to improve the quality and integration of mental health care of these beneficiaries. Parallel to health care provider decision support, it uses specialised mental health managed care interventions to promote effective self-care by beneficiaries suffering from moderate to severe mental illness. Enrolment is subject to meeting clinical criteria, which identifies moderate to severe symptoms or discharge from hospital for mental illness or substance abuse disorder. Eligibility for enrolment also includes beneficiary consent to participate as well as sharing of information with relevant health care providers.

Did you know that one in three South Africans will suffer from a mental health disorder in his or her lifetime and that a person’s physical, social and financial wellbeing is closely tied to their mental health?

HOW DOES IT BENEFIT YOU?

The programme provides effective collaboration between a care manager and family practitioners, psychiatrists, psychologists and other healthcare professionals, who will work together to ensure that you are supported in a way that suits your individual needs. Your adherence and active participation in treatment is required to achieve the desired outcomes and we encourage you to make the most of the opportunities and support that this programme has to offer. While enrolled on the programme you may expect to receive the following support:

  • Education for you and your family
  • Referral to community support groups
  • Support and guidance

A telephonic helpline is available to any beneficiary suffering from a mental health condition or problems with substance (drug and alcohol) abuse. This will provide you with direct access to a care manager who will assess your eligibility for enrolment on the programme, explain the programme to you as well as inform you about the benefits available to manage your condition.

HOW CAN YOU ACCESS THE BENEFIT?

You may access the programme by either:

Calling 0860 106 155, or
Emailing nedgroupmentalhealth@medscheme.co.za

Alternatively you may be identified through predictive modelling and contacted by one of the care managers for enrolment on the programme.

WHAT DOES THE BENEFIT CONSIST OF?

When you enrol on the mental health programme, a care template will be triggered which will provide additional benefit to ensure that your team of healthcare professionals may optimally manage your condition. This will be individualised based on your unique requirements, making this a tailored benefit structured specifically for you, ensuring the best possible outcome.
 

GoSmokeFree Programme


Now available on all Plans!

The GoSmokeFree programme is aimed at helping members who smoke to kick the habit!

Studies show that 70% of smokers would like to give up smoking and 30% go on to attempt to stop each year … yet fewer than 3% successfully quit cold turkey! It has also become clear that the most effective smoking cessation intervention is a combination of behaviour change techniques, medication and support – that is why the GoSmokeFree Stop Smoking Programme uses all these techniques.

HOW DOES IT BENEFIT YOU?

Stopping smoking is the single most important decision you can make for your health. The benefits of stopping smoking are almost immediate, but stopping smoking is not easy, as nicotine is highly addictive and smoking is associated with social activities such as drinking or eating and psychological factors such as work pressure, anxiety and body weight concerns.

The GoSmokeFree Stop Smoking Programme is available at various pharmacies throughout South Africa using a trained Nursing Sister or Pharmacist, so access to the programme is easy.

HOW WILL THIS BENEFIT BE COVERED?

This benefit will be covered from your overall annual limit and will not reduce your Everyday Services Benefits.

HOW CAN YOU ACCESS THE BENEFIT?

Visit www.gosmokefree.co.za to find out more and to locate your nearest pharmacy.
Call 0860 100 080 for more information
 

Back and Neck Rehabilitation Programme

The DBC back and neck rehabilitation programme consists of up to 12 sessions over a 6-week period. The treatment takes place at specific DBC centres.

The DBC Treatment System was developed in Finland more than 20 years ago and today the DBC network spans treatment providers in more than 22 countries. The DBC system is completely evidence and outcomes based with a current global success rate in excess of 85% after an average of 3 to 9 weeks’ treatment. Every centre in the DBC network provides treatment data to DBC Finland and this data is used for quality control and reporting.

HOW TO ACCESS THE PROGRAMME

You can access the programme in various ways.

The Scheme may refer you to the programme if:

  • you request a pre-authorisation for an admission related to back/neck surgery (for example a spinal fusion), pain management (for example a rhizotomy) or specialised radiology (for example an MRI scan), or
  • the Scheme’s predictive model identifies you as being at risk of a back/neck admission in the next year (if you haven’t yet visited one of the accredited centres).

As the list of centres is still limited, the Scheme will only identify and contact members within 30km of a DBC centre and these are the members that we contact, as we often find that members who have to travel more than 30km would decline the Programme.

  • Your specialist or GP may refer you to participate in the Programme.
  • You may self-refer by contacting the Scheme on 0860 100 080, should you experience chronic, ongoing back or neck pain.

PROGRAMME VS SURGERY – IMPLICATIONS

See the chapter Co-Payments, Penalties and Out-of-Pocket Expenses for more information.

WHERE ARE THE DBC CENTRES?

There are DBC centres throughout South Africa, with additional centres opening on an ongoing basis.
Please call 0860 106 155 or visit www.dbcsa.co.za to find the DBC centre closest to you.

Oncology Benefit Management Programme


(For cancer patients)

Refer to 16. Oncology under Services and procedures covered during hospitalisation for benefit limits.

If you are diagnosed with cancer, it will be to your advantage to contact the Oncology Case Manager before starting any treatment. The Oncology Benefit Management Programme will not only help you to manage the high costs associated with treatment, but you will also receive help, support and education on your condition from the Oncology Case Manager.

The Scheme has appointed the Nedgroup Oncology Network as our Designated Service Provider for oncology. If you are referred to a provider for oncology-related treatment, please check with your administrator whether the provider is part of the Nedgroup Oncology Network.

WHY IS IT NECESSARY FOR ME TO REGISTER ON THE ONCOLOGY BENEFIT MANAGEMENT PROGRAMME?

By enrolling in the programme, you will qualify for the annual oncology family benefit limit. It will also ensure that health services related to oncology, such as your doctor’s consultations, general and specialised radiology and pathology during follow-up visits to the doctor, will be covered from your oncology benefit. By obtaining authorisation you are also ensuring that your treatment is effectively managed within your available benefits.

This benefit forms part of your Hospital and Trauma Benefits. It is envisaged that in most cases this limit will be sufficient to cover well-managed costs.

If your care plan is not approved, you will not have access to the oncology benefit limit, and all your cancer-related accounts will be paid from your Everyday Services Benefits.

The Oncology Case Manager will address any concerns with the treating oncologist.

Please submit your care plan to cancerinfo at medscheme.co.za

If you have any queries regarding the Oncology Benefit Management Programme or your condition, please contact the Oncology Case Manager on 0860 100 572.

UPGRADE TO ACCESS ENHANCED BENEFITS

If you or one of your dependants are diagnosed with cancer or have to undergo oncology treatment and your Plan does not provide adequately for the cancer treatment, you can apply to upgrade to Traditional, Comprehensive or Platinum Plans within two months (60 days) after the date of the first diagnosis of cancer, or having had to undergo oncology treatment.

 

HOW TO OBTAIN AUTHORISATION FOR ASSOCIATED TREATMENT

1. Surgery/procedures/hospital admissions:

If you need to be admitted to hospital for chemotherapy or radiotherapy, please contact the Oncology Management Department directly.

Surgery or related procedures are covered from the hospital benefits and not the oncology benefit, so you will need to obtain a pre-authorisation from the Hospital Pre-authorisation Department.

2. Specialised radiology (including PET scans):

If you require specialised radiology, such as CT, MRI or PET scans, you will need an additional authorisation from the Oncology Management Department for it to be covered from your oncology benefit.

When applying for a specialised radiology authorisation, the following information is required:

  • membership number
  • dependant number
  • requesting doctor practice number
  • radiology practice number
  • codes to be charged and estimated cost
  • reason for the scan

If you need an authorisation for a PET scan, your doctor must complete the PET scan form, which is available at all PET scan units.

3. Hospice, private nursing and medical admissions:

If you need services such as home nursing or hospice, you need to contact the Hospital Pre-authorisation Department. You can also contact this department if you have complications such as dehydration or excessive vomiting, or need to be hospitalised for pain control.

4. Social worker:

An Oncology Social Worker Benefit, subject to the Oncology Benefit limit, for the payment of seven sessions with a social worker affiliated to the Nedgroup Oncology Network in the case of terminal cases.

PLEASE NOTE

The account claims process and claims queries are not handled by the Oncology Case Manager. These queries should be directed to the General Enquiries call centre.

 

HIV Management Programme

Members and dependants of the Nedgroup Medical Aid Scheme have access to benefits for the treatment of HIV. These benefits can be accessed by registering on the HIV management programme and all Nedgroup Medical Aid Scheme members are entitled to join.

HIV

For most people HIV is a frightening disease, but today treatment is available that allows the majority of people living with HIV to lead healthy and productive lives for many years.

Action and Information

The first step is to find out whether you have been infected with HIV and what you can do to protect your loved ones and stay healthy. Medicines are available to attack the virus, while vitamins, good nutrition and exercise can play a critical role in keeping your body strong and healthy. Starting treatment at the right time ensures the effectiveness of the medicines, improves quality of life and decreases the risk of serious infections or other complications. Our HIV management programme can help you access benefits to assist you with the best way of managing HIV.

We can help you to manage your condition

Our HIV management programme is specifically for HIV-related medicine. This programme is used to pay for medicine to attack the virus, vitamins to boost your immune system and regular monitoring tests.

Your condition will stay confidential

HIV is a sensitive matter and every effort is made to keep your condition confidential. The staff members have all signed confidentiality agreements and are employed in a separate company from the Scheme or the administrator. Staff who manage the HIV management programme will not reveal your HIV status to anyone without your permission. The HIV management programme uses separate telephone, fax and private mailbag facilities from the Scheme or the administrator. Patients need to use these facilities to maintain confidentiality.

You must register on our HIV management programme

If your test shows you are HIV-positive you must register on the HIV management programme as soon as possible to make use of this benefit. Telephone in confidence and ask for an application form and the counsellor will also assist you with registering on the HIV management programme. Your doctor can also contact us on your behalf.

After you have registered

After you receive the application form, you and your doctor must complete it and return it to the HIV management programme by using the confidential, toll-free fax line number on the form. A highly qualified medical team will examine your details and if necessary, discuss an appropriate treatment with your doctor.

Once treatment has been agreed upon, you and your doctor will be sent a detailed treatment plan, which explains the approved medicine as well as the regular tests that need to be done to ensure that the medicines are working correctly.

What the HIV management programme offers you

The Scheme’s HIV management programme is a complete HIV disease management programme that offers both members and beneficiaries:

  • Medicine to treat HIV (including drugs to prevent mother-to-child transmission and infection after sexual assault or needle stick injury) at the most appropriate time.
  • Treatment to prevent opportunistic infections like certain serious pneumonias and tuberculosis.
  • Regular monitoring of disease progression and response to therapy.
  • Regular monitoring tests to pick up possible side-effects of treatment.
  • Ongoing patient support via a Treatment Support Line.
  • Clinical guidelines and telephonic support for doctors.
  • Help in finding a registered counsellor for emotional support.

Managed by Aid for AIDS (AfA)

Tel: 0860 100 646

Fax: 0800 60 0773

Email: afa@afadm.co.za

Website: aidforaids.co.za

Mobisite: aidforaids.mobi

SMS (call me): 083 410 9078

The HIV Care Manager will assist with all your questions regarding the condition, its treatment, social issues or any concerns that you may have.

 

Renal Dialysis and Organ Transplant Programme

If you need to undergo renal dialysis or an organ transplant, you must submit a care plan.

A 12-month care plan must be submitted to, and approved by, the Case Manager.

This plan should include the following information:

  • date of diagnosis
  • the area concerned
  • any prior surgery or treatment
  • ICD10 code
  • tariff code
  • practice number of doctor or supplier
  • new treatment requested as well as approximate costs

Please submit your care plan to:
Hospital Benefit Management

Fax: 0860 21 22 23 or 021 466 1913

Email: nedgroup.authorisations@medscheme.co.za

 

Active Disease Risk Management Programme

The Nedgroup Medical Aid Scheme Active Disease Risk Management Programme identifies members who are at risk of suffering complications or advancement of their chronic conditions. The programme will assist you to control, manage and monitor your conditions. With your prior consent, your health coach will work together with you and your GP.

If you have been diagnosed or are at potential risk of developing a chronic condition, you may have access to our dedicated health coaches who will be on hand to advise and provide guidance to you. This will be communicated to you in various ways to provide support, information and practical advice to better manage or prevent chronic conditions.

Members registered on the programme will have access to a health line to discuss any chronic conditions confidentially with a health coach, as well as be encouraged to access HealthCloud on the Member Zone. This is an online educational web and mobile health portal that gives members access to a range of resources to assist with better health choices which includes e-tutorials and educational articles, tools and quizzes.

Please note the following

  • The health coaches are not able to diagnose or treat health problems over the phone and the advice provided does not replace a visit to your doctor.
  • All information regarding your medical condition will be kept strictly confidential.

Active Disease Risk Management Department

Telephone: 0860 106 155
Fax: 0860 106 245
Email: membercare@medscheme.co.za

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