Co-Payments, Penalties and Out-of-Pocket Expenses

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 Hospital Network and 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 appendectomy R2 500 The alternative, if you do not want to incur the co-payment, would be to undergo open surgery.
Laparoscopic hernia repair R2 500
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.
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.
are on the Platinum, Comprehensive or Traditional Plan and have a non-emergency hip or knee replacement that is not undertaken by the Scheme’s Designated Service Providers (DSPs) a R10 000 co-payment (unless you do not live within 30km of a DSP). Choose one of the Scheme’s DSPs for your surgery. They are ICPS, JointCare, Major Joints for Life (as from 1 March 2021), and Care Expert (for Platinum Plan only), 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.
NEW!
are on the Savings or Hospital Network Plan and want to have a non-emergency hip or knee replacement that does not qualify as PMB
the full cost of the procedure from your own pocket. Consider upgrading to one of the higher-end Plans that cover hip and knee replacements.

 

  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. Alternatively your GP or pharmacist (with relevant practice numbers) can call the Scriptpharm on 011 100 7557 to request an update in terms of the strength or quantity of any of your existing authorised chronic medicines.
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.
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 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:

    • you will incur a R2 500 admission co-payment (unless you are on the 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 Networks, 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.

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