Benefits 2020: Overview



 

Anybody who has experienced a health scare can testify that any other problem suddenly becomes small once a health risk becomes apparent. That’s why a quality medical scheme is no longer a nice-to-have, but a must have. The Nedgroup Medicial Aid Scheme aims to offer our members the best possible value for money. As a restricted membership medical scheme, we have several factors that count in your favour…

 

THE SCHEME –
THERE FOR YOU

 

One goal and one goal only: improving the health of our members

As a restricted membership scheme we are not for profit, but simply want to ensure that you and your dependants have great medical cover and the support you need to live a healthy life.

Savings are passed on directly to you

Unlike open schemes, we don’t have to spend a lot of money on marketing to attract new members. This is just one of the ways in which we save… and thus pass the savings on to you. In fact, independent benchmarking shows that our benefits are comparable with those offered by the top open-membership schemes, but that our contributions are much lower!

We look for reasons to pay claims

Open schemes usually apply strict conditions around the payment of benefits, as paying more than what is legally required may have a negative impact on their surplus levels and related profitability. Generally they do not pay ex gratia claims. Our objective is breaking even and maintaining our solvency ratio. We therefore pay claims within our rules and also offer ex-gratia assistance to our members through a managed governance process.

Bells and whistles… we’ve got them, too!

Open schemes are in competition with each other for the same member pool, and often add extra benefits to make their offering more attractive… gym memberships and the like. With our partner Sanlam Reality, we can now also offer you a lifestyle rewards programme where you can pay a minimal monthly fee and enjoy extras such as heavily discounted gym fees, movies, flights and more!

overview family

 

the-same

ALL OUR PLANS OFFER:

hospital trauma
Unlimited Hospital and trauma cover (with sub-limits on certain benefits and certain PMB-only benefits on the Hospital Network and Savings Plans, and a list of hospitals on the Hospital Network Plan)
Emergency transport and telephonic support by ER24
Preventative screening tests and vaccines through our Health Screening benefits
managed care
Access to various Managed Care Programmes
Cover for all Prescribed Minimum Benefits (PMB) chronic conditions

 

different

THE PLANS DIFFER MAINLY IN HOW THE FOLLOWING ARE COVERED:

Everyday services benefits
Everyday services benefits
Non-PMB chronic conditions icon
Non-PMB chronic conditions
PLATINUM

Flexibility for a healthy family with a higher income who wants excellent cover for everyday services benefits such as GP consultations.

Offers the highest benefits, paying up to 3 x Medical Scheme Rate (MSR). Covers PMB and approved non-PMB conditions from a set benefit limit, then from Routine Medical Benefit, then covers PMB unlimited.
COMPREHENSIVE

Cover for higher healthcare needs, especially chronic conditions, with a savings allocation allowing more flexibility for everyday services benefits.

Covers certain benefits from a personal medical savings account, allowing more flexibility. Covers approved non-PMB conditions from a set benefit limit; PMB conditions unlimited.
TRADITIONAL

Cover for medium healthcare needs, especially chronic conditions, with sublimits on everyday services benefits.

Covers listed benefits up to pre-set sub-limits. Covers approved non-PMB conditions from a set benefit limit; PMB conditions unlimited.
SAVINGS

Maximum flexibility for a generally healthy family who is happy to have everyday services covered from an annual savings allocation.

Covers all benefits from funds available in the personal medical savings account. Covers both PMB and approved non-PMB from a set benefit limit, then covers PMB unlimited.
HOSPITAL NETWORK

If you have no immediate healthcare needs, but want the peace of mind of having cover mainly for unforeseen hospital procedures and serious diseases.

Restricted cover for everyday services (1 network GP consultation). Cover only for PMB conditions and Major Depression.
WONDERING
WHAT PLAN TO CHOOSE?

 

Weigh up your needs with what you can afford…

needs-vs-cost-banner
 

YOUR NEEDS

  • How healthy are you and your loved ones? What were your medical expenses during the previous benefit year, and do you anticipate any medical procedures or any need for high-cost drugs during the next benefit year?
  • Do you prefer to pay less for a Plan that does not cover much in the way of day-to-day medical needs, or would you rather pay more and have a Plan that offers more comprehensive cover for day-to-day medical needs?
  • Do you or any of your loved ones suffer from a chronic disease that would require chronic medicine or treatment? If so, is it a condition that is covered by all the Plans, or only by the higher-cost Plans (or not at all)?

 

WHAT YOU CAN AFFORD

  • Use our handy calculator tool to calculate your family’s monthly contribution rate for each Plan to make sure that you can afford the Plan you select. Before moving to a lower-cost Plan, make sure that you will still have good enough cover for your medical needs.

calculator

Remember that you can only change Plans once a year and that is before the start of the benefit year on 1 January. No Plan changes are allowed during the year, except for a Plan upgrade to access enhanced oncology benefits.

TIP: If you are retiring during the next benefit year, choose a Plan which will take into account your financial circumstances at retirement.

YOUR BENEFITS
FOR 2020
IMPORTANT!
This is an overview only – please see the 2020 Member Guide for specific amounts and rates,
as well as conditions that may apply.

BENEFITS: HOSPITAL AND TRAUMA

NEW! If you are on the Hospital Network Plan, avoid incurring a R7 000 co-payment by only using hospitals on the Network for non-emergencies.

 
All Plans offer unlimited cover for major medical expenses (but with sub-limits on certain procedures and benefits).

Claims are paid at Medical Scheme Rate or cost or medicine price, whichever is the lesser. Remember that conditions such as pre-authorisation, co-payments and case management may apply – see the 2020 Member Guide.
 

Emergency IN AN EMERGENCY

You and your loved ones have access to emergency medical transportation (if authorised by ER24) 24 hours a day, 7 days per week, in South Africa, Lesotho, Swaziland, Zimbabwe, Botswana, Namibia, Mozambique and Angola. (Call +27 102 053 038 if outside the borders of South Africa.)

phone FOR MEDICAL ADVICE

ER24 also has an “Ask the Nurse” medical advice and information line. Although it is not possible to make an accurate diagnosis over the phone, this can help you decide whether you need an ambulance, see your doctor, or simply go to the pharmacy.

BENEFITS: HEALTH SCREENING

 
To help you and your loved ones prevent disease, all Plans offer screening tests and vaccinations.

Blood sugar
Blood pressure
Cholesterol
Measurement of height, weight and waist circumference
Body Mass Index calculation
HIV Screening
Vaccinations
Pap smear
Prostate Specific Antigen
Mammogram
Colorectal screening
Glaucoma screening
Bone density screening
Remember that certain benefit limits and conditions apply, and that the Health Screening Benefits do not include the consultation cost itself, as this is payable from your available Everyday Services Benefits. All screening tests will be covered at the Medical Scheme Rate (MSR). If the provider charges more than MSR, the difference will be for your account. See the 2020 Member Guide.

 

“Thank goodness I used my Health Screening Benefits and had my blood pressure checked. I never even suspected that I had an issue, but thanks to the Scheme I can now manage my high blood pressure so that it doesn’t become a serious problem.”
Male member, aged 23

 

BENEFITS: MANAGED CARE PROGRAMMES

Qualifying members have access to the following programmes, at no additional cost:

Diabetes Management Programme
Mental Health Programme
GoSmokeFree Programme
Back and Neck Rehabilitation Programme
Oncology Benefit Management Programme
HIV and AIDS Management Programme
Renal Dialysis and Organ Transplant Programme
Active Disease Risk Management Programme
Remember that certain benefit limits and conditions such as treatment protocols apply – see the 2020 Member Guide for more information.

 

“The Back and Neck Programme really changed my life – how wonderful to no longer be in constant pain! Yes, it takes time and effort to do the exercises that I have been prescribed … but it is so worthwhile that I do them with a smile each day!”
Female pensioner, aged 72

BENEFITS: CHRONIC MEDICINE

 

Conditions covered
PMB chronic conditions
All Plans offer treatment for the official PMB chronic conditions, as well as for Major Depression.
Non-PMB chronic conditions small
All Plans except Hospital Network Plan offer treatment for a number of additional Scheme-approved chronic conditions.

 

How benefits are paid
 
It is important to understand the different ways in which the Plans cover chronic medicine (for example, although Platinum Plan is a higher-cost plan with richer day-to-day benefits, it is typically not suited to members with both PMB and non-PMB chronic conditions).

 

PLATINUM
PMB chronic conditions All chronic medicine benefits (both PMB and non-PMB) are first covered from a set chronic medicine benefit limit (R11 340 per family per year for 2020).
Non-PMB chronic conditions small

 

SAVINGS
PMB chronic conditions All chronic medicine benefits (both PMB and non-PMB) are first covered from a set chronic medicine benefit limit (R11 340 per family per year for 2020).
Non-PMB chronic conditions small

 

TRADITIONAL
COMPREHENSIVE
Non-PMB chronic conditions small A set chronic medicine benefit amount is used to cover non-PMB conditions (R11 340 per family per year for 2020).
PMB chronic conditions PMB conditions are covered separately, and unlimited.

 

HOSPITAL NETWORK
Non-PMB chronic conditions small A set chronic medicine benefit amount is used to cover Major Depression only (R4 430 per family per year for 2020).
PMB chronic conditions PMB conditions are covered separately, and unlimited.
Pharmacy Direct is the DSP.

 

“I was so happy when the Scheme contacted me to let me know that the medication we have been claiming for from our Everyday Services Benefits could rather be covered from our Chronic Medicine Benefits, as our daughter’s condition was a PMB chronic condition and would be covered unlimited – suddenly our benefits are going so much further!”
Male member, aged 51
Remember that certain benefit limits and conditions such as treatment protocols apply – see the 2020 Member Guide.

 

PMB chronic conditions
THE OFFICIAL PMB CONDITIONS
Addison’s disease, Asthma, Bipolar mood disorder, Bronchiectasis, Cardiac failure, Cardiomyopathy, Chronic renal disease, Chronic obstructive pulmonary disease (emphysema), Coronary artery disease (angina pectoris and ischaemic heart disease), Crohn’s disease, Diabetes insipidus, Diabetes mellitus type 1 & 2, Dysrhythmias, Epilepsy, Glaucoma, Haemophilia, HIV/AIDS, Hormone replacement therapy, Hyperlipidaemia (high cholesterol), Hypertension (high blood pressure), Hypothyroidism, Multiple sclerosis, Parkinson’s disease, Rheumatoid arthritis, Schizophrenia, Systemic lupus erythematosus and Ulcerative colitis.
Non-PMB chronic conditions small
ADDITIONAL SCHEME-APPROVED CHRONIC CONDITIONS
Acne (cystic nodular), Allergic rhinitis (no criteria for Platinum, Comprehensive and Traditional Plans, while for Savings Plan will only be approved for children under the age of 12 years, or for patients on concurrent asthma therapy), Anxiety (if linked to another approved psychiatric chronic condition), Attention deficit syndrome (if prescribed by a specialist and under the age of 18 years), Behcet’s Disease, Deep vein thrombosis, Depression/Mood disorders, Eczema, GORD, Gout, Hyperthyroidism, Hypofunction of the pituitary gland, Insomnia (sleep disorders) (if linked to another approved psychiatric chronic condition), Migraine prophylactics (prevention), Obsessive Compulsive Disorder, Paget’s Disease, Psoriasis and Sjogren’s Disease.

In addition, for Platinum, Comprehensive and Traditional Plans: Alzheimer’s disease, Urinary tract infections, Cystitis, Chronic Sinusitis, Osteoarthritis and Osteoporosis.

 

BENEFITS: EVERYDAY SERVICES

 

Benefits are paid at up to 3 x MSR.
Sub-limits are available for certain benefits. Other specific benefits are covered from the Routine Medical Benefit (RMB) limit.
Once these sub-limits are depleted, the available RMB limit can also be used to cover the above benefits.
Once your sub-limits and RMB are depleted, you will be liable for payment.

ROUTINE MEDICAL
BENEFIT LIMIT

Member: R20 450
Member +1: R34 380
Member +2: R36 450
Member +3: R44 300
This benefit can also be used to pay for certain other services, once you have used up those limits.

15% of your monthly contribution is allocated to your PMSA. Benefits with sub-limits are paid at MSR, while benefits payable from PMSA are covered at cost.
Sub-limits are available for certain benefits. Other specific benefits are covered from your Personal Medical Savings Account (PMSA).
Once your sub-limits and/or PMSA (whichever is applicable to the specific benefit) are depleted, you will be liable for payment.

ANNUAL PMSA AMOUNT
(AVAILABLE UPFRONT)

Add up the amounts per beneficiary to calculate the total available for your family.

If you earn R4 500 pm or less Member: R7 842
Adult: R6 117
Child (max 2): R1 740
If you earn between R4 500 and R6 000 pm Member: R7 995
Adult: R6 237
Child (max 2): R1 782
If you earn between R6 001 and R10 000 pm Member: R8 034
Adult: R6 267
Child (max 2): R1 794

If you earn more than R10 000 pm from April 2020

Member: R8 160
Adult: R6 366
Child (max 2): R1 839

Benefits are paid at MSR.
Sub-limits are available for certain benefits.
Once your sub-limits are depleted, you will be liable for payment.

21.3% of your monthly contribution is allocated to your PMSA. Benefits with sub-limits are paid at MSR, while benefits payable from PMSA are covered at cost.
Most of the listed benefits are covered from your Personal Medical Savings Account (PMSA). Sub-limits are available for certain maternity benefits only.
Once your sub-limits and/or PMSA (whichever is applicable to the specific benefit) are depleted, you will be liable for payment.

ANNUAL PMSA AMOUNT
(AVAILABLE UPFRONT)

Add up the amounts per beneficiary to calculate the total available for your family.

If you earn R6 000 pm or less Member: R5 598
Adult: R4 812
Child (max 2): R1 710
If you earn between R6 001 and R10 000 pm Member: R5 718
Adult: R5 088
Child (max 2): R1 785
If you earn more than R10 000 pm Member: R6 105
Adult: R5 988
Child (max 2): R2 028

HOSPITAL NETWORK
1 x Network GP consultation per beneficiary per year. NEW!

 
Remember that certain benefit limits and conditions such as treatment protocols apply – see the 2020 Member Guide.

  PLATINUM COMPREHENSIVE TRADITIONAL SAVINGS
consultations
Consultations:
General Practitioners, Homeopaths and Specialist consultations
platinum-check
Payable from Routine Medical Benefit.
comprehensive-check
Covered from available PMSA.
traditional-check

savings-check
Covered from available PMSA.
optical
Optical benefits:
Eye tests, lenses, contact lenses and fittings
platinum-check
Additional sub-limits available. Once exhausted, payable from Routine Medical Benefit limit.
comprehensive-check
Sub-limits available, with frames covered from available PMSA.
traditional-check

savings-check
Covered from available PMSA.
maternity
Maternity benefits:
Antenatal visits
Ultrasound scans
Antenatal classes
platinum-check
Additional sub-limits available.
comprehensive-check

traditional-check

savings-check
Additional sub-limits available.
dentistry
Dentistry:
Basic dental services and advanced dentistry
platinum-check
Additional sub-limits available. Once exhausted, payable from Routine Medical Benefit limit.
comprehensive-check

traditional-check

savings-check
Covered from available PMSA
medicines
Medicines:
Prescribed medicine (acute) Pharmacy advised therapy (PAT)
platinum-check
Payable from Routine Medical Benefit.
comprehensive-check
Covered from available PMSA.
traditional-check

savings-check
Covered from available PMSA.
pathology
Pathology

platinum-check
Payable from Routine Medical Benefit.
comprehensive-check

traditional-check

savings-check
Covered from available PMSA.
radiology
Radiology (X-rays)

platinum-check
Payable from Routine Medical Benefit.
comprehensive-check

traditional-check

savings-check
Covered from available PMSA.
supplementary
Supplementary health services (for example, chiropody, chiropractic services, speech therapists, biokinetics)

platinum-check
Payable from Routine Medical Benefit.
comprehensive-check
Covered from available PMSA.
traditional-check

savings-check
Covered from available PMSA.
physio
Physiotherapy

platinum-check
Payable from Routine Medical Benefit.
comprehensive-check
Covered from available PMSA.
traditional-check

savings-check
Covered from available PMSA.
psycology
Psychology

platinum-check
Payable from Routine Medical Benefit.
comprehensive-check

traditional-check

savings-check
Covered from available PMSA.
appliances
Medical appliances
(including CPAP)
platinum-check
Payable from Routine Medical Benefit.
comprehensive-check

traditional-check

savings-check
Covered from available PMSA.
wheelchair
Wheelchair and associated appliances

platinum-check
Additional sub-limits available.
comprehensive-check

traditional-check

savings-check
Covered from available PMSA.
hearing-aids
Hearing aids

platinum-check
Payable from Routine Medical Benefit.
comprehensive-check

traditional-check

savings-check
Covered from available PMSA.
contraceptives
Oral contraceptives

platinum-check
Additional sub-limits available, including for Mirena device.
comprehensive-check
Covered from available PMSA.
traditional-check
Payable from Prescribed medicine (acute) sub-limit.
savings-check
Covered from available PMSA.
CONTRIBUTIONS
FOR 2020

 

calculator

1 January 2020 – 31 March 2020
(same amounts as from April 2019)
Member Adult Child (max 2)
PLATINUM
All income levels R5 211 R4 065 R1 248
COMPREHENSIVE (includes 15% allocation to PMSA)
R0 – R4 500.99 pm R3 867 R3 016 R851
R4 501R6 000.99 pm R4 210 R3 283 R941
R6 001 + pm R4 295 R3 350 R970
TRADITIONAL
0R6 000.99 pm R3 720 R2 900 R816
R6 001 + pm R3 793 R2 959 R880
SAVINGS (includes 21.3% allocation to PMSA)
0R6 000.99 pm R2 075 R1 786 R634
R6 001 + pm R2 262 R2 220 R753
HOSPITAL NETWORK
0R6 000.99 pm R1 278 R1 112 R403
R6 001 + pm R1 587 R1 563 R545
 
1 April 2020 – 31 December 2020
 
Member Adult Child (max 2)
PLATINUM
All income levels R5 680 R4 431 R1 360
COMPREHENSIVE (includes 15% allocation to PMSA)
Up to R10 000.99 pm R4 526 R3 529 R1 012
R10 001 + pm R4 617 R3 601 R1 043
 
TRADITIONAL
Up to R10 000.99 pm R3 999 R3 118 R877
R10 001 + pm R4 077 R3 181 R946
SAVINGS (includes 21.3% allocation to PMSA)
Up to R10 000.99 pm R2 231 R1 920 R682
R10 001 + pm R2 432 R2 387 R809
HOSPITAL NETWORK
Up to R10 000.99 pm R1 318 R1 146 R415
R10 001 – R20 000.99 R1 665 R1 640 R572
R20 001 + pm R1 698 R1 672 R583

Contributions for active employees are based on Total Guaranteed Package (TGP).

HOW TO SAVE MONEY AND MAKE THE MOST
OF YOUR BENEFITS

 

This is how you can save money:

 

 

Use the Scheme’s pharmacy network to avoid unnecessary co-payments.
Use a doctor/specialist on the Network to avoid unnecessary co-payments.
Consider paying in cash and then claiming back to get discounts (unless you are registered on the Chronic Medicine Management programme).
Get a quote from the doctor before undergoing any procedure and check with the Contact Centre how much will be paid.
Ask for generic medicine whenever possible.
If you are registered for chronic medicine, consider using Pharmacy Direct as courier pharmacy, so that you can save travelling costs and avoid the possibility that your medication may be out of stock.
Think twice about undergoing elective surgery procedures.
If your doctor recommends a particular line of treatment and you feel uncertain about whether it is necessary, ask for a second opinion.
If an operation is scheduled for the afternoon or evening, arrange for hospital admission after 12pm.
Maintain a healthy lifestyle, as prevention is always the better option.
Make healthier choices to avoid or better manage lifestyle-related chronic conditions.
Use the screening tests and vaccines offered as part of your Health Screening Benefits to identify potential lifestyle diseases early.

IF YOU WANT TO SEE
A SPECIALIST

 

To ensure co-ordinated care, and to minimise unnecessary costs, members should be referred to any specialists by their GP. To create a specialist referral, the GP needs to access the Medscheme interactive voice system to obtain a specialist referral number.

The referral number will apply to either a type of specialist (for example, a dermatologist) or a specific specialist for a period of time that the GP decides on, which can be up to 6 months. The patient still has the choice of which specialist to visit.

There are some exceptions to this rule and members will not need a specialist referral number in the following instances:

  • 1 visit per year to a gynaecologist for a gynaecological check-up and pap smear for female patients
  • 1 visit per year to a urologist for a check-up for male patients
  • Visits to a paediatrician for children under 1 year of age
  • Visits to optical and dental specialists
  • Maternity consultations by a gynaecologist
  • Medical management under the Prescribed Minimum Benefit treatment plan

In case of an emergency, where a patient had to consult a specialist without prior authorisation, a referral number can be obtained after the visit. The patient would need to contact his/her GP to obtain the referral number within 72 hours of the emergency.

Members should remember that obtaining a referral number from a GP is not a guarantee of full payment – specialist consultations will be paid up to the Medical Scheme Rate, or such rate as agreed with the specialist, and subject to available benefits. Authorisations will only be valid for six months.

Please remember that all members except those on the Platinum Plan will in future have a 30% co-payment for consultations with specialists if they were not referred by their GP.

CO-PAYMENTS, PENALTIES
OR OUT-OF-POCKET EXPENSES YOU CAN EXPECT

 

In an effort to manage escalating healthcare costs and over-utilisation of benefits, the Scheme has implemented certain co-payments that would apply under certain circumstances. For ease of reference, this section gives an overview of all the co-payments that you may incur. Depending on your decisions, you may incur one or a combination of these.

  HOSPITALISATION

If you are admitted to hospital … … you will have to pay What you can do to avoid additional costs:
for a non-emergency and your admitting practitioner is not part of the Nedgroup GP or Specialist Networks, your claims will be covered at Medical Scheme Rate, and…
  • the difference between what you are charged by the medical service provider and Medical Scheme Rate (on ALL Plans), PLUS
  • a co-payment of R2 500, at the point of admission to the hospital(on all Plans except Platinum).
Make sure that your admitting practitioner is on the Nedgroup Network, as your hospital claims will then be covered up to 2 x Medical Scheme Rate and you will not have a R2 500 co-payment on hospital bills.
for a non-emergency and you do not contact the Scheme before you are admitted to hospital to pre-authorise your admission (unless it is a valid emergency), …
  • a penalty of R500 (and even run the risk of not having your hospital claims covered).
Always pre-authorise a hospital admission, as well as in-hospital tests such as MRI, radio-isotope or CAT scans, at least three days beforehand. In an emergency, the Scheme must be notified on the first working day after the admission.
for back and neck pain and you did not have an assessment via the Back and Neck Rehabilitation Programme …
  • a co-payment of R2 500, at the point of admission to the hospital.
If you have back and neck pain, register on the Scheme’s Back and Neck Rehabilitation Programme for an assessment.

 
In addition, for members/beneficiaries on the HOSPITAL NETWORK PLAN

If you are admitted to a NON-NETWORK hospital… … you will have to pay What you can do to avoid additional costs:
for a non-emergency a co-payment of R7 000, at the point of admission to the hospital. Use only hospitals that are on the specified list of hospitals for the Hospital Network Plan.

 

  LAPAROSCOPIC SURGERY AND OTHER PROCEDURES WITH CO-PAYMENTS

Laparoscopic procedures are more expensive, and the procedure may in general be performed as an open procedure. The Scheme, like many other medical schemes, funds these procedures with a co-payment, rather than only cover open procedures.

If you have any of the following procedures*… … you will have a co-payment of What you can do to avoid additional costs:
Upper GI endoscopy (gastroscopy) R500 If performed in a doctor’s rooms, no co-payment will apply.
Laparoscopic hernia repair R2 500 The alternative, if you do not want to incur the co-payment, would be to undergo open surgery.
Laparoscopic hysterectomy R2 500
Laparoscopic radical prostatectomy R2 500
Laparoscopic pyeloplasty R2 500
Knee arthroscopy R2 500 Certain hospital gap cover products may cover the procedure co-payment.
Balloon sinuplasty R2 500
In-hospital dental work and you are on the Comprehensive, Traditional or Savings Plan (or Hospital Network Plan for removal of impacted wisdom teeth only) R1 500

*These co-payments will not apply if the procedure qualifies under the Prescribed Minimum Benefits. Please see Prescribed Minimum Benefits for more information.
 

  NON-EMERGENCY SPINAL FUSION AND HIP/KNEE REPLACEMENTS

If you … … you will have to pay What you can do to avoid additional costs:
live reasonably close to a DBC Centre but declined going for an assessment via the Back and Neck Rehabilitation Programme before undergoing non-emergency spinal fusion or laminectomy surgery a R25 000 co-payment (unless you do not live within 30km of a DSP) Register on the Scheme’s Back and Neck Rehabilitation Programme for an assessment.
went for an assessment at DBC and were deemed eligible for the Back and Neck Rehabilitation Programme, but declined to enrol on the programme before going for non-emergency spinal fusion or laminectomy surgery a R25 000 co-payment (unless you do not live within 30km of a DSP) Register on the Scheme’s Back and Neck Rehabilitation Programme.
have a non-emergency hip or knee replacement that is not undertaken by the Scheme’s Designated Service Providers, ICPS or JointCare a R10 000 co-payment (unless you do not live within 30km of a DSP) Choose ICPS or JointCare, two groups of orthopaedic surgeons that specialise in performing hip and knee replacements, for your surgery. Call 0860 100 080 for details of a DSP orthopaedic surgeon closest to you.

 

  CONSULTATIONS WITH SPECIALISTS

If you … … you will have to pay What you can do to avoid additional costs:
consult a specialist, without your GP getting a referral for the visit from the Scheme a 30% co-payment on the cost of the consultation with the specialist Make sure your GP gets a referral number from the Scheme.

 

  PHARMACY CLAIMS – PMB, NON-PMB AND ONCOLOGY

If you claim for … … then What you can do to minimise your costs and make your benefits go further:
medicine dispensed by a non- Nedgroup Network Pharmacy For PMB chronic medication, only 75% of the medicine cost will be covered from the chronic medicine benefit. There will be a 25% co-payment at the point of sale, for which you will be liable.

For non-PMB chronic medication, in other words medication used to treat Scheme-approved additional chronic conditions (which are Plan-specific), you will be liable for 100% of the cost at the point of sale.

Use a Nedgroup Network Pharmacy for all your PMB and non-PMB chronic medication – call the chronic medicine department for a Nedgroup Network Pharmacy provider in your area.
oncology specialised drugs You need to make use of the Scheme’s DSP, Pharmacy Direct. If you obtain your medication from a pharmacy other than Pharmacy Direct, there will be a 25% co-payment at the point of sale, for which you will be liable. Use Pharmacy Direct to obtain oncology specialised drugs.

 

  CHRONIC MEDICINE BENEFITS

If you claim for a medicine… … then What you can do to avoid co-payments or additional costs:
that is not approved on the chronic medicine programme (benefit) or is not an approved formulary generic The claim will be not be processed and paid from the chronic benefit.

It may be covered from a different benefit or you may be liable to pay for the medication.

  • Apply for the chronic medicine programme before claiming any chronic related medicine.
  • Ensure that your application form is accompanied by relevant supporting documentation and a copy of a valid doctor’s prescription.

Please note clinical entry criteria and formularies are applied, which will determine the outcome of your chronic application

that is not listed on the Chronic Medicines Formulary or is not the approved item(s) on your chronic authorisation decision letter The claim for the medication will be rejected and you will be liable to pay for the medication. If you do not want to incur this cost, use medicine on the Chronic Medicines Formulary. This list of cost-effective medicines is based on local and international studies, and complies with the criteria developed by the Council for Medical Schemes.

Members should take their chronic decision letter with them to their pharmacy provider, to ensure that the correct product is claimed.

that is changed in terms of the strength or dosage or medicine type The claim for the medication will be rejected and you will be liable to pay for the medication. Send any prescription updates to the chronic medicine department for review and for authorisation updates before claiming any new medication deemed to be chronic.
for a chronic condition that is not on the list of PMB chronic conditions, or on the list of additional Scheme approved conditions (which are Plan-specific) The claim will be paid from your available Everyday Services Benefits (from the acute medicine sub-limits, where applicable), not from your Chronic Medicine Benefits. You can apply for an ex gratia payment, which will then be considered by the Scheme’s ex gratia committee. Please note, however, that ex gratia applications are only granted in exceptional and deserving cases.
PMB medication and you are on the Hospital Network Plan, but you do not use Pharmacy Direct You will have to make a 25% co-payment. Use only Pharmacy Direct, the DSP for the Hospital Network Plan, for PMB medication claims.
for depression and you are on the Hospital Network Plan, but you do not use Pharmacy Direct You will have to pay in full for the medicine, as it is not PMB medication. Use only Pharmacy Direct, the DSP for the Hospital Network Plan, for depression medication claims.
NEW! HIV medication You need to make use of one of the Scheme’s DSPS, Pharmacy Direct or Clicks Pharmacy. If you obtain your medication from a pharmacy other than these DSPs, there will be a 25% co-payment at the point of sale, for which you will be liable. Use Pharmacy Direct or Clicks Pharmacy to obtain NEW HIV medication.

See Chronic Medicine Benefits for more information.
 

  MANAGEMENT OF PRESCRIBED MINIMUM BENEFITS (PMB) CONDITIONS

If you … … the following will apply What you can do to minimise your costs and make your benefits go further:
are diagnosed with a PMB condition and choose to consult with a GP or specialist that is not on the Nedgroup Network
  • Your claims for consultations will be covered at Medical Scheme Rate and be paid from your available Everyday Services Benefits (except for Hospital Network Plan).
  • If your Everyday Services Benefits become exhausted, or you are on the Hospital Network Plan, the service will be covered from your PMB benefit, with a 25% co-payment that you will need to cover from your own pocket.
  • If you are admitted to hospital for a PMB condition and it is not an emergency,

    • you will incur a R2 500 admission co-payment (unless you are on Platinum Plan), and
    • your hospital-related claims will only be paid at Medical Scheme Rate and you will be liable for the difference.
  • If you are on the Hospital Network Plan and you are admitted to a non-network hospital for a PMB condition and it is not an emergency,

    • you will incur a R7 000 admission co-payment and
    • your hospital-related claims will only be paid at Medical Scheme Rate and you will be liable for the difference.
Choose a GP or specialist on the Nedgroup Network, as your PMB-related accounts will then be paid from the PMB benefit at a Scheme-agreed rate, and you will not be liable for any co-payment on your specialist’s claim, should you be admitted to hospital.

 

  ONCOLOGY CONSULTATIONS

If you claim for … … you will have to pay What you can do to minimise your costs and make your benefits go further:
a consultation with a non-ICON oncologist The difference between what is charged and the cover of Medical Scheme Rate Use the Scheme’s DSP for oncology treatment, Independent Clinical Oncology Network (ICON), as consultations are covered at a negotiated fee. ICON is a dedicated network of oncologists committed to the comprehensive management of members with cancer.

INFORMATION FOR RETIREES
AND OTHER CONTINUATION MEMBERS

 

What happens when a member retires?

If you belong to the Scheme before you retire, you can choose to continue to belong to the Scheme, in which case you will be called a continuation member. (Retirees who were not members of the Scheme before retirement do not qualify for membership after retirement.)

PLEASE REMEMBER THAT:

If you choose to leave the Scheme after retirement, you cannot join the Scheme again at a later stage.

 

What happens if the member passes away?

If the member passes away, dependants have the choice to become continuation members. In such a case, the Scheme needs to receive the following documents within three months of the member’s date of death to ensure continuation membership for the dependants:

  1. Copy of the death certificate of the member.
  2. Copy of the ID of the surviving spouse/ beneficiary.
  3. Copy of bank statement or cancelled cheque to upload bank details for debit order/refund purposes.
  4. Proof of income of the continuation member who will become the new main member – SARS assessment (ITA34) or Scheme affidavit.

PLEASE REMEMBER THAT:

Dependants of a deceased member who elect not to join the Nedgroup Medical Aid Scheme following the member’s death do not qualify to join the Scheme at a later stage.

Related topics

Back to Top