ALL OUR PLANS OFFER:

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

Access to various Managed Care Programmes

Cover for all Prescribed Minimum Benefits (PMB) chronic conditions

THE PLANS DIFFER MAINLY IN HOW THE FOLLOWING ARE COVERED:

	Everyday services benefits	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.

Weigh up your needs with what you can afford…

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.

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.
 

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.)

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

 

All Plans offer treatment for the official PMB chronic conditions, as well as for Major Depression.

All Plans except Hospital Network Plan offer treatment for a number of additional Scheme-approved chronic conditions.

 

 

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

	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).

 

SAVINGS

	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).

 

TRADITIONAL

COMPREHENSIVE

A set chronic medicine benefit amount is used to cover non-PMB conditions (R11 340 per family per year for 2020).

PMB conditions are covered separately, and unlimited.

 

HOSPITAL NETWORK

A set chronic medicine benefit amount is used to cover Major Depression only (R4 430 per family per year for 2020).

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.

 

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.

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.

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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

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

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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

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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: General Practitioners, Homeopaths and Specialist consultations	Payable from Routine Medical Benefit.	Covered from available PMSA.		Covered from available PMSA.
Optical benefits: Eye tests, lenses, contact lenses and fittings	Additional sub-limits available. Once exhausted, payable from Routine Medical Benefit limit.	Sub-limits available, with frames covered from available PMSA.		Covered from available PMSA.
Maternity benefits: Antenatal visits Ultrasound scans Antenatal classes	Additional sub-limits available.			Additional sub-limits available.
Dentistry: Basic dental services and advanced dentistry	Additional sub-limits available. Once exhausted, payable from Routine Medical Benefit limit.			Covered from available PMSA
Medicines: Prescribed medicine (acute) Pharmacy advised therapy (PAT)	Payable from Routine Medical Benefit.	Covered from available PMSA.		Covered from available PMSA.
Pathology	Payable from Routine Medical Benefit.			Covered from available PMSA.
Radiology (X-rays)	Payable from Routine Medical Benefit.			Covered from available PMSA.
Supplementary health services (for example, chiropody, chiropractic services, speech therapists, biokinetics)	Payable from Routine Medical Benefit.	Covered from available PMSA.		Covered from available PMSA.
Physiotherapy	Payable from Routine Medical Benefit.	Covered from available PMSA.		Covered from available PMSA.
Psychology	Payable from Routine Medical Benefit.			Covered from available PMSA.
Medical appliances (including CPAP)	Payable from Routine Medical Benefit.			Covered from available PMSA.
Wheelchair and associated appliances	Additional sub-limits available.			Covered from available PMSA.
Hearing aids	Payable from Routine Medical Benefit.			Covered from available PMSA.
Oral contraceptives	Additional sub-limits available, including for Mirena device.	Covered from available PMSA.	Payable from Prescribed medicine (acute) sub-limit.	Covered from available PMSA.

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

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.

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.

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

 
In addition, for members/beneficiaries on 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.

*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

  CONSULTATIONS WITH SPECIALISTS

  PHARMACY CLAIMS – PMB, NON-PMB AND ONCOLOGY

  CHRONIC MEDICINE BENEFITS

See Chronic Medicine Benefits for more information.
 

  MANAGEMENT OF PRESCRIBED MINIMUM BENEFITS (PMB) CONDITIONS

  ONCOLOGY CONSULTATIONS

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.)

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.

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