2021 MEMBER GUIDE - Nedgroup Medical Aid Scheme
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2021 MEMBER GUIDE
For additional valuable information,
visit our website at nmas.co.za
CONTENTS
1. GET IN TOUCH 4
2. THE SCHEME – THERE FOR YOU 7
3. DIGITAL TOOLS 8
4. 2021 EMPLOYEE CONTRIBUTIONS 10
5. OVERVIEW OF THE FIVE PLANS 11
6. BENEFITS: HEALTH SCREENING 13
7. BENEFITS: MANAGED CARE PROGRAMMES 15
8. BENEFITS: EVERYDAY SERVICES 22
9. BENEFITS: CHRONIC MEDICINE 27
10. BENEFITS: HOSPITAL AND TRAUMA 29
11. BENEFITS: HEALTHCARE COSTS WHILE TRAVELLING 40
12. BENEFITS: EMERGENCY SERVICES 41
13. IF YOU WANT TO SEE A SPECIALIST 44
14. CO-PAYMENTS, PENALTIES AND OUT-OF-POCKET EXPENSES 45
15. INFORMATION FOR RETIREES AND OTHER CONTINUATION MEMBERS 49
16. HOW TO SAVE MONEY AND MAKE THE MOST OF YOUR BENEFITS 50
This member guide is an abbreviated print version sent to pensioners. For additional information on membership,
maternity benefits, exclusions and more, please refer to our website, nmas.co.za.
2 | NMAS Member Guide 2020
Get
Get in
in Touch
Touch
1 GET IN TOUCH
The Scheme
Digital
Tools
If you prefer the 24-hour SELF-HELP facility
1. Call 0860 100 080
2. When the following menu is read out, choose option 2, “If you are an existing member please press 2”.
Contributions
3. You will then be prompted to enter your membership number, “Please enter your membership
number followed by the # key”.
4. The system will recognise your medical scheme membership number and offer you the
appropriate menus.
The Plans
For enquiries about the BENEFITS available to you, MEMBERSHIP, or other GENERAL
QUESTIONS and issues
• Use the Member App or WhatsApp (see Digital Tools chapter for more information)
Screening
Health
• Email nedgroup.enquiries@medscheme.co.za (benefit and general enquiries, including
claims and refunds, plus payment of savings balances to members leaving the Scheme) or
nedgroupregistry@medscheme.co.za (enquiries about membership and credit control only)
• Call 0860 100 080 (or 011 671 6833)
Managed
Care
• Fax 0860 111 784/011 758 7041
To submit a CLAIM or follow up on the payment of claims
Use the Member App or WhatsApp (see Digital Tools chapter for more information)
Everyday
Services
For new claims:
• Email to nedgroup.newclaims@medscheme.co.za / Fax your accounts to 0860 111 784
Chronic
To follow up on claims:
• Login to the Member Zone to view your claims
• Call 0860 100 080
& Trauma
Hospital
• Email nedgroup.enquiries@medscheme.co.za
For claims refunds:
• Email to refundmember@medscheme.co.za Travel
To get AUTHORISATION for a hospital admission
• Email nedgroup.authorisations@medscheme.co.za
Emergencies
• Call 0860 100 080
• Fax 0860 21 22 23 or 021 466 1913
To check whether your provider is on the GP or Specialist NETWORK, or to find one who is
Specialists
• Email nedgroup.enquiries@medscheme.co.za
• Call 0860 100 080
HOSPITAL To check where your closest NETWORK HOSPITAL is (only for members on
NETWORK
Co-payments
Hospital Network Plan):
PLAN
• Email nedgroup.enquiries@medscheme.co.za
• Call 0860 100 080
• Refer to the Network Hospital list on the website: nmas.co.za
Members
Retiring
NMAS Member Guide 2021 | 4
Get
Get in
in Touch
Touch
OTHER TOUCHPOINTS
In an EMERGENCY, or for
• Call: 0861 084 124
The Scheme
the ‘Ask a Nurse’ HELPLINE:
• Email cqc@er24.co.za for Customer Relations
Call 084 124 • Email claimsqueries@er24.co.za for claims or billing queries
• Visit www.er24.co.za
Digital
Tools
To find out where your nearest Network Pharmacy is for preventative SCREENING TESTS
AND VACCINES
Contributions
• Call 0860 100 080
• Email nedgroup.enquiries@medscheme.co.za
To register for the CHRONIC MEDICINE Benefit, update your chronic medication or resolve
any queries related to medicines for the chronic conditions covered by the Scheme, contact
The Plans
ScriptPharm Risk Management
• Call 011 100 7557 / Fax 086 679 1579
• Email nedgroup@scriptpharm.co.za
• Visit www.scriptpharm.co.za
Screening
Health
To obtain a copy of your TREATMENT PLAN, or have it updated
• Call 0860 100 080
• Email nedgroupapmb@medscheme.co.za
Managed
Care
To confirm whether you qualify for the BACK AND NECK REHABILITATION Programme and
to find your closest DBC Centre
• Call 0860 106 155
Everyday
Services
• Email nedgroup.enquiries@medscheme.co.za
• Visit www.dbcsa.co.za
Chronic
To contact the ONCOLOGY Management Programme (for CANCER patients)
• Call 0860 100 572 / Fax 021 466 2303
• Email cancerinfo@medscheme.co.za
& Trauma
Hospital
For the HIV Management Programme, contact Aid for AIDS
• Call 0860 100 646 / 021 466 1700
• Fax 0800 600 773 Travel
• Email afa@afadm.co.za
• Visit www.aidforaids.co.za (or aidforaids.mobi on a smartphone)
Emergencies
• SMS (call me) 083 410 9078
To report suspected FRAUD
• Call 0800 112 811
• Email fraud@medscheme.co.za
Specialists
To claim for medical services you received OUTSIDE SOUTH AFRICA
Email foreign.hos@medscheme.co.za
Co-payments
If you do not have access to email or a fax machine, you can reach us by post:
Nedgroup Medical Aid Scheme, PO Box 174, Vereeniging, 1930
Members
Retiring
NMAS Member Guide 2021 | 5
Get
Get in
in Touch
Touch
WALK-IN CENTRES
You are welcome to visit the following walk-in centres of the Scheme’s administrator, Medscheme.
The Scheme
Bloemfontein 1st Floor, Medical Suites 4 & 5, Middestad Centre, Cnr Charles & West Burger Street
Cape Town Shop 6, 9 Long Street, Cnr Long & Waterkant Street
Digital
Tools
Durban 102 Stephen Dlamini Road, Musgrave
Kathu Shop 18D, Kameeldoring Plein Building, Cnr Frikkie Meyer & Rooisand Road
Contributions
Kimberley Shop 76, North Cape Mall, Royldene
Klerksdorp Shop 11, Medicover Building, 22 Knowles Street, Witkoppies
Lephalale (Ellisras) Bosveld Boulevard Park, Shop 6, Cnr Chris Hani and Joe Slovo Street, Onverwacht
Mahikeng
The Plans
Shop 118, Ground Floor, East Gallery, Mega City
Nelspruit Shop 11, City Centre Mall, Cnr Andrews Street & Madiba Drive
Shop 2, Ground Floor, Shoprite Checkers Centre,
Polokwane
Cnr Hans van Rensburg & Grobler Streets
Screening
Health
Port Elizabeth Block 6, Greenacres Office Park, 2nd Avenue, Newton Park
Pretoria Nedbank Plaza, Shop 17, Ground Floor, 361 Steve Biko Street, Arcadia
Flora Centre, Entrance 2, Shop 21 & 22, Cnr Ontdekkers and Conrad Road,
Managed
Roodepoort
Care
Florida North
Vereeniging Ground Floor, 36 Merriman Avenue
Everyday
Services
ESCALATION PROCESS
We understand that members expect reliable and efficient service from the Scheme at all times. To help you
resolve medical scheme issues you may have, or have a complaint about service you received, please contact the
Chronic
Medscheme Call Centre on 0860 100 080 or via e-mail on nedgroup.enquiries@medscheme.co.za and provide the
details of your complaint. The advantage of going through the Call Centre is that calls are recorded and trends
can be picked up, allowing the Scheme to identify specific communication needs.
& Trauma
Hospital
If you are not satisfied with the outcome, you are requested to make use of the following process to ensure
effective and accurate resolution of your query.
If you are not satisfied,
LEVEL 1 Request the assistance of an Escalation Consultant telephonically.
Travel
go to level 2.
If you are still not
LEVEL 2 Request assistance via email to memberfeedback@medscheme.co.za.
satisfied, go to level 3.
Emergencies
Request the details of the Administration Manager or the Fund If you are still not
LEVEL 3
Manager to escalate to. satisfied, go to level 4.
If you are still not
LEVEL 4 Request the details of the Assistant Principal Officer.
Specialists
satisfied, go to level 5.
LEVEL 5 Request the details of the Principal Officer.
Co-payments
If, after following the procedure detailed above, you are still not satisfied with the outcome of the process, or you
have not received a response within seven (7) working days, you may contact the Council for Medical Schemes’
Complaints Department: Telephone 012 431 0500 / Fax 012 431 0608 / Send your complaint via the Council’s
website www.medicalschemes.com (follow the “Consumer Assistance – Complaints link”)
Members
Retiring
NMAS Member Guide 2021 | 6
Get in Touch
THE SCHEME –
2 THERE FOR YOU
The
The Scheme
Scheme
Digital
Tools
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
Contributions
restricted membership medical scheme, we have several factors that count in your favour…
One goal and one goal only: Savings are passed on
improving the health of our directly to you
members
The Plans
Unlike open schemes, we don’t have to spend a lot
As a restricted membership scheme we are not for of money on marketing to attract new members.
profit, but simply want to ensure that you and your This is just one of the ways in which we save… and
dependants have great medical cover and the support thus pass the savings on to you. In fact, independent
Screening
Health
you need to live a healthy life. 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
Managed
Care
Bells and whistles…
Open schemes usually apply strict conditions around
the payment of benefits, as paying more than what is
we’ve got them, too!
legally required may have a negative impact on their
Everyday
Open schemes are in competition with each other
Services
surplus levels and related profitability. Generally they for the same member pool, and often add extra
do not pay ex gratia claims. Our objective is breaking benefits to make their offering more attractive… gym
even and maintaining our solvency ratio. We therefore memberships and the like. With our partner Sanlam
pay claims within our rules and also offer ex-gratia Reality, we can now also offer you a lifestyle rewards
Chronic
assistance to our members through a managed programme where you can pay a minimal monthly fee
governance process. and enjoy extras such as heavily discounted gym fees,
movies, flights and more!
& Trauma
Hospital
Travel
WHAT ARE SOME OF MY RESPONSIBILITIES AS A MEMBER?
• Understand how the Scheme and specific Plans work • Inform the Scheme before you are admitted
Emergencies
by reading this Member Guide and all communication to hospital or within 24 hours of an emergency
sent to you by the Scheme. admission to hospital.
• Keep the Scheme up to date on any changes to your • File all your documentation regarding the Scheme
membership details. so that you can refer to it if necessary.
Specialists
• Check whether the correct contributions are • Keep your membership card in a safe place so that
deducted from your salary/pension or bank account. no-one else can use it fraudulently.
(Child dependants 23 years or older will pay the adult • Choose a Plan that best suits your needs. Although
dependant contribution.) HR and Medscheme as administrator can offer
Co-payments
• Check all accounts from service providers as well you information, neither of these parties is allowed
as your statements and claims advices from the to offer you financial advice such as which Plan
Scheme to make sure that all your details are correct to choose.
and that your claims have been processed correctly.
This will also help to identify fraud.
Members
Retiring
NMAS Member Guide 2021 | 7
Get in Touch
3 DIGITAL TOOLS OUR NEW
The Scheme
MEMBER
APP IS NOW
LIVE!
Digital
Digital
Tools
Tools
MEMBER APP DOWNLOAD OUR NEW MEMBER APP NOW:
Packed with cutting-edge technology and a host of Search Nedgroup Medical Aid Scheme Member App in
your app store. Once you have downloaded the app,
Contributions
innovative tools, our member app is an all-in-one
powerhouse of possibilities that will help you to manage follow the prompts to register.
your membership and benefits, and stay in touch with
We have created a quick tour to guide you, which
us. It even features lifestyle functionality that will
is available via the menu buttons at the top of the
transform your day-to-day health and wellness journey.
landing page.
The Plans
Screening
MEDICATION
Health
THE MEMBER APP INSTANT ASSISTANCE
MANAGER
• Simplicity-centric with • Scan and save your • Technical support
practical layout and medication for easy • Quick access to
Managed
navigation recollection with your emergency numbers on
Care
• Get notified of important phone’s camera the Member App
Scheme communication • Set medication reminders
• Chat to our live agents via • Over 8 000 medications
NedChat recognised
Everyday
Services
MAKING
YOUR PLAN
APPOINTMENTS
Chronic
• Healthfindr • Access your monthly
• Search for healthcare benefit statements
providers • Find documents like:
& Trauma
Hospital
• Book appointments at Member guide and
clinics and pharmacies Newsletters
• Appointment reminders • Your e-card
• Book virtual consultations • Your tax certificates Travel
with a VirtualCare doctor
Emergencies
NEDCHAT
Find NedChat on the Member App to:
Specialists
• Clarify simple enquiries without having to call the
Now fully
Contact Centre or sending emails.
integrated
• Ask benefit and/or claims-related questions.
with the
• Attach documentation (even claims) to a message
Co-payments
and forward it directly to the consultant. Member App
• Send a photo of any document as an attachment.
• View an electronic version of your membership card.
Members
Retiring
NMAS Member Guide 2021 | 8
Get in Touch
SCHEME WEBSITE
The accessible and user-friendly Scheme website • Information on the website is ‘nested’ within
The Scheme
is available to all members who have access to the expandable drop-down boxes, making it easy to
internet, and on multiple devices such as desktops, navigate. Combined with our powerful search
laptops, tablets and smartphones. facility, you can quickly find the information you
are looking for.
• A handy Find it Fast section on the home page
Digital
Digital
• You can also find updates in the News section, with a
Tools
Tools
offers direct links to the information members most
special Covid-19 Hub offering relevant updates and
often search.
resources during the Covid-19 pandemic.
• In addition to the information in the member guide
• You can navigate to the logged-in Member Zone via
Contributions
(which is focused more on benefits), the website
the website – simply click LOGIN in the menu.
offers comprehensive information on topics such
as membership, claiming, etc.
• Our handy online calculator makes it easy to calculate
your family’s contributions and PMSA (if your Plan
The Plans
has a savings component).
TIP: If you are visually
impaired, you can use Ctrl+ to
increase the font size on your
Screening
desktop in increments. Simply
Health
press Ctrl- to make the display
smaller, or Ctrl0 to return to
the default view size.
Find it at
Managed
Care
nmas.co.za
Everyday
Services
Chronic
WHATSAPP
Our WhatsApp functionality is 100% private and secure. To get started, add the number +27 60 070 2673 to your
phone’s contact list, and then send a message with the word “Hi” to start the conversation. You will be presented
& Trauma
Hospital
with several options.
This is what you can do… Travel
See your latest claims status
Emergencies
Access your membership eCard and
share it with a GP or family member
Specialists
Downloads – tax certificate,
membership certificate and member
statement
Co-payments
Access our COVID-19
information hub
Members
Retiring
NMAS Member Guide 2021 | 9
Get in Touch
2021 EMPLOYEE
4 CONTRIBUTIONS
The Scheme
Digital
Tools
1 January 2021 - 31 March 2021
VALUE-ADD
(same amounts as from April 2020)
• Even if you have more children under age
Contributions
Contributions
Member Adult Child (max 2) 23, you only pay for two.
PLATINUM • A child over age 23 who is physically
All income levels – monthly R5 680 R4 431 R1 360 or mentally disabled and financially
COMPREHENSIVE (includes 15% allocation to PMSA) dependent on you, qualifies for child rates.
The Plans
Up to R10 000.99 R4 526 R3 529 R1 012 • A child over age 23 who is financially
R10 001 + R4 617 R3 601 R1 043 dependent on you can be registered as
an additional adult dependant.
TRADITIONAL
Screening
Up to R10 000.99 R3 999 R3 118 R877
Health
R10 001 + R4 077 R3 181 R946
SAVINGS (includes 21.3% allocation to PMSA)
Up to R10 000.99 R2 231 R1 920 R682
Managed
Care
R10 001 + R2 432 R2 387 R809
HOSPITAL NETWORK
Up to R10 000.99 R1 318 R1 146 R415
Everyday
Services
R10 001 – R20 000.99 R1 665 R1 640 R572
R20 001 + R1 698 R1 672 R583 TIP:
Use our handy
online calculator
Chronic
1 April 2021 - 31 December 2021 to automatically
calculate your
Member Adult Child (max 2) family’s monthly
PLATINUM contributions.
& Trauma
Hospital
All income levels – monthly R5 992 R4 675 R1 435
COMPREHENSIVE (includes 15% allocation to PMSA)
Up to R10 000.99 R4 766 R3 716 R1 066
Travel
R10 001 + R4 862 R3 792 R1 098
TRADITIONAL
Emergencies
Up to R10 000.99 R4 211 R3 283 R923
R10 001 + R4 293 R3 350 R996
SAVINGS (includes 21.3% allocation to PMSA)
Up to R10 000.99 R2 309 R1 987 R706
Specialists
R10 001 – R20 000.99 R2 517 R2 471 R837
R20 001 + R2 565 R2 518 R853
HOSPITAL NETWORK
Co-payments
Up to R10 000.99 R1 371 R1 192 R432
R10 001 – R20 000.99 R1 732 R1 706 R595
Contributions for active employees are based on
R20 001 + R1 766 R1 739 R606 Total Guaranteed Package (TGP).
Members
Retiring
NMAS Member Guide 2021 | 10Get in Touch
OVERVIEW
5 OF THE FIVE PLANS
The Scheme
Digital
Tools
THE
ALL OUR PLANS OFFER:
Contributions
SAME ...
The
The plans
Unlimited Hospital and Emergency Preventative Access to Cover for all
Plans
trauma cover (with sub- transport and screening tests various Prescribed
limits on certain benefits and telephonic and vaccines Managed Care Minimum Benefits
certain PMB-only benefits support by through Programmes (PMB) chronic
Screening
on the Hospital Network ER24 our Health conditions
Health
and Savings Plans, and Screening
a list of hospitals on the benefits
Hospital Network Plan)
Managed
Care
HOW TO CHOOSE A PLAN
Everyday
Services
Weigh up your needs with what you can afford…
YOUR
NEEDS • How healthy are you and your loved ones? What were your medical
Chronic
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?
& Trauma
• Do you prefer to pay less for a Plan that does not cover much in the
Hospital
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? Travel
• 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)?
Emergencies
Use our handy calculator tool to calculate your family’s monthly
WHAT
contribution rate for each Plan to make sure that you can afford the
YOU CAN
Plan you select. Before moving to a lower-cost Plan, make sure that
AFFORD
you will still have good enough cover for your medical needs.
Specialists
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
Co-payments
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.
Members
Retiring
NMAS Member Guide 2021 | 11Get in Touch
The Scheme
... BUT
THE PLANS DIFFER MAINLY IN HOW THE
DIFFERENT FOLLOWING ARE COVERED:
Digital
Tools
Contributions
Everyday services Non-PMB chronic
benefits conditions
PLATINUM Covers PMB and approved
Offers the highest benefits, non-PMB conditions from a set
The
The plans
Flexibility for a healthy family with a
paying up to 3 x Medical benefit limit, then from Routine
Plans
higher income who wants excellent
Scheme Rate (MSR). Medical Benefit, then covers PMB
cover for everyday services benefits
unlimited.
such as GP consultations.
Screening
Health
COMPREHENSIVE
Covers certain benefits from
Covers approved non-PMB
Managed
Cover for higher healthcare needs, a personal medical savings
conditions from a set benefit
Care
especially chronic conditions, with account, allowing more
limit; PMB conditions unlimited.
a savings allocation allowing more flexibility.
flexibility for everyday services benefits.
Everyday
Services
TRADITIONAL
Covers approved non-PMB
Covers listed benefits up to
Cover for medium healthcare needs, conditions from a set benefit
Chronic
pre-set sub-limits.
especially chronic conditions, with sub- limit; PMB conditions unlimited.
limits on everyday services benefits.
& Trauma
Hospital
SAVINGS
Covers all benefits from funds Covers both PMB and approved
Maximum flexibility for a generally
available in the personal non-PMB from a set benefit
Travel
healthy family who is happy to have
medical savings account. limit, then covers PMB unlimited.
everyday services covered from an
annual savings allocation.
Emergencies
HOSPITAL NETWORK
Restricted cover for everyday
If you have no immediate healthcare Cover only for PMB conditions
Specialists
services (1 network GP
needs, but want the peace of mind of and Major Depression up to
consultation and one dentist
having cover mainly for unforeseen a set benefit limit.
consultation.)
hospital procedures and serious
diseases.
Co-payments
Members
Retiring
NMAS Member Guide 2021 | 12Get in Touch
The Scheme
Digital
Tools
Contributions
The Plans
6
screening
Screening
Health
Health
BENEFITS:
HEALTH SCREENING
Managed
Care
Everyday
Services
Why should I go for screening tests? these screening tests is that members with potentially
Having screening tests done is one of the most high risks in terms of their health may be identified
important things you can do for your health. Screenings at an early stage.
Chronic
are medical tests that check for diseases before there You will be covered for the following diagnostic tests
are any known symptoms. Screenings can help doctors (two sets, or you will have the flexibility to choose to
find diseases early, when the diseases may be easier have all the tests at one encounter, either at a health
to treat. Do bear in mind, though, that screening tests
& Trauma
screening event or at a Nedgroup Network Pharmacy,
Hospital
are only indicative. For a more accurate diagnosis of a or to have multiple individual tests over the benefit
chronic condition, your doctor may refer you for more year, subject to the benefit limit of R355):
extensive blood tests to determine whether you require
chronic medication. For more information please call Measurement of height, weight and
Travel
0860 100 080. waist circumference
What is available under the Health Body Mass Index calculation
Emergencies
Screening Benefits?
Blood sugar
The following Health Screening Benefits are
available to members on ALL Plans:
Blood pressure
TIP:
Specialists
To book a health
HEALTH SCREENING Cholesterol
screening at a pharmacy
clinic, or for more information
You have access to the Nedgroup Network Pharmacy about the process, visit
Screening Programme, allowing you and your dischem.co.za/wellness-clinic
Co-payments
dependants to visit a participating Nedgroup Network for Dis-Chem or
pharmacy clinic or attend a Scheme health screening clicks.co.za/clinicBooking
event, so that a qualified nurse can give you advice on for Clicks Pharmacies.
how to improve your health. Another advantage of
Members
Retiring
NMAS Member Guide 2021 | 13Get in Touch
The Scheme
If you would
like information
on where you can
Digital
Tools
access the screening
tests, please call All screening
0860 100 080. tests will be
covered at the Medical
Contributions
Scheme Rate (MSR).
If the provider charges
more than MSR, the
difference will be for
HIV SCREENING your account.
The Plans
You also have the following HIV tests and services
VACCINATIONS
available on all Plans:
• Pre-testing counselling, The following vaccinations are covered under the
screening
Screening
Health
Health
• Testing and post-test counselling. Health Screening Benefits:
Your monthly statement will reflect any claims received • One flu vaccine per beneficiary per benefit year.
and paid once this benefit has been accessed. The • One pneumococcal vaccine per beneficiary aged 65
Managed
claims are paid from your HIV Benefit and not from or over every 5 years.
Care
your Everyday Services Benefits. • One HPV vaccine course per female beneficiary
aged 9-26.
CANCER SCREENING TESTS
Everyday
Services
PLEASE NOTE
Pap smear (usually performed by a GP or ONLY the vaccines are covered under this benefit,
gynaecologist) – limited to one test per whereas any consultation fees will be paid
female beneficiary per benefit year. from the Everyday Services Benefits limit (for
Chronic
applicable Plans) or, in the case of Savings Plan
Prostate Specific Antigen (a blood test to
members with insufficient savings or Hospital
screen for prostate cancer) – limited to one
Network Plan members who have already used
test per male beneficiary over age 45 per
their benefit of one GP consultation, from the
& Trauma
Hospital
benefit year.
member’s own pocket.
Mammogram (performed at a radiology
practice) – limited to one test per female
beneficiary over age 40 per benefit year. OTHER SCREENING TESTS
Travel
Colorectal screening (where a sample of your Glaucoma screening (performed at an
stool is screened by a pathologist) – limited optometrist/ophthalmologist) – limited to
Emergencies
to one test per beneficiary over age 50 per one test per beneficiary over age 55.
benefit year.
Bone density screening (performed at a
radiology practice) – limited to one test per
PLEASE NOTE beneficiary over age 65 every two years.
ONLY the tests are covered under this benefit;
Specialists
whereas any consulting fees will be paid from Your monthly statement will reflect any claims received
the Everyday Services Benefits limit (for and paid once this benefit has been accessed.
applicable Plans) or, in the case of Savings Plan
The claims are paid from your Health Screening
members with insufficient savings or Hospital
Co-payments
Benefit and not from your Everyday Services Benefits.
Network Plan members who have already used
Any medical expenses not covered under the Health
their benefit of one GP consultation, from the
Screening Benefit will be paid from your Everyday
member’s own pocket.
Services Benefits.
Members
Retiring
NMAS Member Guide 2021 | 14Get in Touch
The Scheme
Digital
Tools
Contributions
The Plans
Screening
Health
Managed
Managed
Care
Everyday
Services
Chronic
7
& Trauma
Hospital
BENEFITS: MANAGED CARE
PROGRAMMES
Travel
Emergencies
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
Specialists
Managed Care Programmes:
NEW - Weight Management Programme - HIV Management Programme
- Diabetes Management Programme - Oncology Benefit Management Programme
Co-payments
- GoSmokeFree Programme - Renal Dialysis and Organ Transplant Programme
- Back and Neck Rehabilitation Programme - Active Disease Risk Management Programme
- Mental Health Programme
Members
Retiring
NMAS Member Guide 2021 | 15Get in Touch
NEW WEIGHT MANAGEMENT PROGRAMME
The Scheme
Being overweight, and especially being obese, Suitable candidates will be enrolled on a 12-week
substantially increases your risk of chronic conditions, programme that includes weekly group-exercise
including hypertension, abnormal cholesterol levels, type sessions, one-on-one consultations with a biokineticist,
2 diabetes, coronary artery disease, stroke, gallbladder and referral to a dietician and psychologist, if necessary.
Digital
Tools
disease, osteoarthritis, sleep apnea and respiratory
problems, as well as cancers of the endometrium, HOW CAN YOU ACCESS THE BENEFIT?
breast, prostate, and colon. If you think that you may qualify and you are interested
in this programme, contact Member Care for more
Contributions
Obesity is a complex disease that is dependent on many information, or to confirm whether you qualify:
factors, including a person’s genetics and lifestyle. It
is important to implement a longer-term, sustainable Call 0860 106 155 or
plan that will lead to a healthier lifestyle, which is what Email membercare@medscheme.co.za
the Scheme’s Weight Management Programme aims
The Plans
You will typically qualify to take part in this
to help members do.
Programme if:
WHAT DOES THE WEIGHT MANAGEMENT
• BMI*: Your body mass index (BMI) is 30 or more, or
PROGRAMME ENTAIL?
• WAIST CIRCUMFERENCE: You are a man with a
Screening
Qualifying members will be referred to a biokineticist,
Health
where a full assessment will be undertaken to waist circumference of 102 cm or more, or a woman
determine his or her suitability for the programme. with a waist circumference of 88 cm or more, or
This will include: • MOTIVATED CASE: Your general practitioner or a
BASA biokineticist motivates your case (for example,
Managed
Managed
• an online lifestyle questionnaire;
Care
if your BMI is between 25 and 30 and you have
• validated biometric testing, including blood pressure, diabetes and comorbidities).
cholesterol, blood sugar levels, height and weight
(BMI); and * To calculate your BMI, divide your weight in kilograms
(kg) by your height in metres (m), and then divide the
Everyday
Services
• a fitness assessment.
answer by your height again. This will give you your
At the end of the assessment the member will receive BMI in kg/m2.
a comprehensive health status report with tailored
recommendations for health improvement.
Chronic
DIABETES MANAGEMENT PROGRAMME
& Trauma
Hospital
The Scheme’s Diabetes Management programme and diabetic educators to allow you to effectively
helps members with diabetes better understand this manage your diabetes. Travel
long-term condition and empowers them to make the
right decisions to stay healthy. In addition, you will have access to a dedicated Health
Coach to answer any questions you may have, and you
Emergencies
As most diabetics have at least one other chronic will also enjoy online assistance through HealthCloud.
condition, the programme offers a personalised care
plan to ensure that your specific needs are taken into HOW TO ACCESS THE PROGRAMME
account. The care plan will provide cover for the tests For more information, or to register on this programme:
required for the management of diabetes as well
Call 0860 100 080 or
Specialists
as your other chronic conditions. It offers access to
Email membercare@medscheme.co.za
specialised diabetes doctors, dieticians, podiatrists
The Scheme believes that managing diabetes should be based on the principles of patient-centred care and
Co-payments
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.
Members
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NMAS Member Guide 2021 | 16Get in Touch
NOW
AVAILABLE
ON ALL
GOSMOKEFREE PROGRAMME PLANS!
The Scheme
The GoSmokeFree programme is aimed at helping eating and psychological factors such as work pressure,
members who smoke to kick the habit! anxiety and body weight concerns.
Studies show that 70% of smokers would like to give up The GoSmokeFree Stop Smoking Programme is
Digital
smoking and 30% go on to attempt to stop each year available at various pharmacies throughout South
Tools
… yet fewer than 3% successfully quit cold turkey! It Africa using a trained Nursing Sister or Pharmacist,
has also become clear that the most effective smoking so access to the programme is easy.
cessation intervention is a combination of behaviour
Contributions
change techniques, medication and support – that HOW WILL THIS BENEFIT BE COVERED?
is why the GoSmokeFree Stop Smoking Programme This benefit will be covered from your overall annual
uses all these techniques. limit and will not reduce your Everyday Services
Benefits.
HOW DOES IT BENEFIT YOU?
HOW CAN YOU ACCESS THE BENEFIT?
The Plans
Stopping smoking is the single most important decision
you can make for your health. The benefits of stopping Visit www.gosmokefree.co.za to find out more
smoking are almost immediate, but stopping smoking and to locate your nearest pharmacy.
is not easy, as nicotine is highly addictive and smoking Call 0860 100 080 for more information
Screening
is associated with social activities such as drinking or
Health
BACK AND NECK REHABILITATION PROGRAMME
Managed
Managed
Care
The DBC back and neck rehabilitation programme have to travel more than 30km would decline to
consists of up to 12 sessions over a 6-week period. enrol on the Programme.
Everyday
Services
The treatment takes place at specific DBC centres. • Your specialist or GP may refer you to participate
in the Programme.
The DBC Treatment System was developed in Finland
more than 20 years ago and today the DBC network • You may self-refer by calling 0860 106 155, should
spans treatment providers in more than 22 countries. you experience chronic, ongoing back or neck pain.
Chronic
The DBC system is completely evidence and outcomes
PROGRAMME VS SURGERY – IMPLICATIONS
based with a current global success rate in excess of
See the chapter Co-Payments, Penalties and Out-of-
85% after an average of 3 to 9 weeks’ treatment.
Pocket Expenses for more information.
& Trauma
Every centre in the DBC network provides treatment
Hospital
data to DBC Finland and this data is used for quality WHERE ARE THE DBC CENTRES?
control and reporting. There are DBC centres throughout South Africa, with
HOW TO ACCESS THE PROGRAMME additional centres opening on an ongoing basis. Please Travel
call 0860 106 155 or visit www.dbcsa.co.za to find the
You can access the programme in various ways.
DBC centre closest to you.
• The Scheme will refer you to the programme if:
Emergencies
- 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
Specialists
- Medscheme’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
Co-payments
centres).
As the list of centres is still limited, the Scheme will
only identify and contact members within 30km of
a DBC centre as we often find that members who
Members
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NMAS Member Guide 2021 | 17Get in Touch
The Scheme
Digital
Tools
Contributions
The Plans
Screening
Health
MENTAL HEALTH PROGRAMME
Managed
Managed
Care
The Mental Health Programme is aimed at beneficiaries • Education for you and your family
with certain mental health conditions and substance • Referral to community support groups
abuse disorders to improve the quality and integration
• Support and guidance.
of mental health care of these beneficiaries. Parallel to
Everyday
Services
health care provider decision support, it uses specialised A telephonic helpline is available to any beneficiary
mental health managed care interventions to promote suffering from a mental health condition or problems
effective self-care by beneficiaries suffering from with substance (drug and alcohol) abuse. This will
moderate to severe mental illness. Enrolment is subject provide you with direct access to a care manager
Chronic
to meeting clinical criteria, which identifies moderate who will assess your eligibility for enrolment on the
to severe symptoms or discharge from hospital for programme, explain the programme to you as well
mental illness or substance abuse disorder. Eligibility as inform you about the benefits available to manage
for enrolment also includes beneficiary consent to
& Trauma
your condition.
Hospital
participate as well as sharing of information with
relevant health care providers. HOW CAN YOU ACCESS THE BENEFIT?
You may access the programme by either:
Did you know that one in three South Africans will Travel
suffer from a mental health disorder in his or her Calling 0860 106 155, or
lifetime and that a person’s physical, social and Emailing Nedgroupmentalhealth@medscheme.co.za
financial wellbeing is closely tied to their mental health?
Emergencies
Alternatively you may be identified through predictive
HOW DOES IT BENEFIT YOU? modelling and contacted by one of the care managers
The programme provides effective collaboration for enrolment on the programme.
between a care manager and family practitioners,
WHAT DOES THE BENEFIT CONSIST OF?
psychiatrists, psychologists and other healthcare
Specialists
professionals, who will work together to ensure that When you enrol on the mental health programme,
you are supported in a way that suits your individual a care template will be triggered which will provide
needs. Your adherence and active participation in additional benefits to ensure that your team of
treatment is required to achieve the desired outcomes healthcare professionals may optimally manage your
Co-payments
and we encourage you to make the most of the condition. This will be individualised, based on your
opportunities and support that this programme has unique requirements, making this a tailored benefit
to offer. While enrolled on the programme you may structured specifically for you, ensuring the best
expect to receive the following support: possible outcome.
Members
Retiring
NMAS Member Guide 2021 | 18Get in Touch
Pharmacy Direct and
Clicks Pharmacy are now
the Designated Service
HIV MANAGEMENT PROGRAMME Providers for HIV
medication. See
The Scheme
page 28.
Members and dependants of the Nedgroup Medical Aid AFTER YOU HAVE
Scheme have access to benefits for the treatment of REGISTERED
HIV. These benefits can be accessed by registering on After you receive the application form, you and your
the HIV management programme and all Nedgroup doctor must complete it and return it to the HIV
Digital
Medical Aid Scheme members are entitled to join.
Tools
management programme by using the confidential,
toll-free fax line number on the form. A highly qualified
HIV
medical team will examine your details and if necessary,
For most people HIV is a frightening disease, but today discuss an appropriate treatment with your doctor.
Contributions
treatment is available that allows the majority of
people living with HIV to lead healthy and productive Once treatment has been agreed upon, you and your
lives for many years. doctor will be sent a detailed treatment plan, which
explains the approved medicine as well as the regular
ACTION AND INFORMATION
tests that need to be done to ensure that the medicines
The Plans
The first step is to find out whether you have been are working correctly.
infected with HIV and what you can do to protect your
loved ones and stay healthy. Medicines are available WHAT THE HIV MANAGEMENT PROGRAMME
to attack the virus, while vitamins, good nutrition OFFERS YOU
and exercise can play a critical role in keeping your The Scheme’s HIV management programme is a
Screening
Health
body strong and healthy. Starting treatment at the complete HIV disease management programme that
right time ensures the effectiveness of the medicines, offers both members and beneficiaries:
improves quality of life and decreases the risk of
serious infections or other complications. Our HIV • Medicine to treat HIV (including drugs to prevent
Managed
Managed
mother-to-child transmission and infection after
Care
management programme can help you access benefits
sexual assault or needle stick injury) at the most
to assist you with the best way of managing HIV.
appropriate time.
WE CAN HELP YOU TO MANAGE YOUR CONDITION • Treatment to prevent opportunistic infections like
Everyday
Our HIV management programme is specifically for
Services
certain serious pneumonias and tuberculosis.
HIV-related medicine. This programme is used to pay
• Regular monitoring of disease progression and
for medicine to attack the virus, vitamins to boost your
response to therapy.
immune system and regular monitoring tests.
• Regular monitoring tests to pick up possible side-
Chronic
YOUR CONDITION WILL STAY CONFIDENTIAL effects of treatment.
HIV is a sensitive matter and every effort is made to
• Ongoing patient support via a Treatment
keep your condition confidential. The staff members
Support Line.
& Trauma
have all signed confidentiality agreements and are
Hospital
employed in a separate company from the Scheme • Clinical guidelines and telephonic support for doctors.
or the administrator. Staff who manage the HIV • Help in finding a registered counsellor for
management programme will not reveal your HIV emotional support.
status to anyone without your permission. The HIV
Travel
Managed by Aid for AIDS (AfA)
management programme uses separate telephone,
fax and private mailbag facilities from the Scheme or Tel: 0860 100 646
the administrator. Patients need to use these facilities
Emergencies
to maintain confidentiality. Fax: 0800 60 0773
YOU MUST REGISTER ON OUR HIV Email: afa@afadm.co.za
MANAGEMENT PROGRAMME
Website: www.aidforaids.co.za
If your test shows you are HIV-positive you must
Specialists
register on the HIV management programme as soon Mobisite: aidforaids.mobi
as possible to make use of this benefit. Telephone in
SMS (call me): 083 410 9078
confidence and ask for an application form and the
counsellor will also assist you with registering on the
Co-payments
HIV management programme. Your doctor can also The HIV Care Manager will assist with all your questions
contact us on your behalf. regarding the condition, its treatment, social issues or
any concerns that you may have.
Members
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NMAS Member Guide 2021 | 19Get in Touch
The Scheme
Digital
Tools
UPGRADE
TO ACCESS
ENHANCED BENEFITS
Contributions
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 Plans
the cancer treatment, you can apply to
upgrade to Traditional, Comprehensive
or Platinum Plan within two months
(60 days) after the date of the first
ONCOLOGY BENEFIT diagnosis of cancer, or having
Screening
Health
MANAGEMENT PROGRAMME had to undergo oncology
(FOR CANCER PATIENTS) treatment.
If you are diagnosed with cancer, it will be to your
Managed
Managed
Care
advantage to contact the Oncology Case Manager cancer-related accounts will be paid from your
before starting any treatment. The Oncology Benefit Everyday Services Benefits.
Management Programme will not only help you to
manage the high costs associated with treatment, The Oncology Case Manager will address any concerns
Everyday
with the treating oncologist.
Services
but you will also receive help, support and education
on your condition from the Oncology Case Manager. • Please submit your care plan to
cancerinfo@medscheme.co.za.
The Scheme has appointed the Nedgroup Oncology
Network as our Designated Service Provider for
Chronic
If you have any queries regarding the Oncology Benefit
oncology. If you are referred to a provider for Management Programme or your condition, please
oncology-related treatment, please check with your contact the Oncology Case Manager on 0860 100 572.
administrator whether the provider is part of the
& Trauma
Hospital
Nedgroup Oncology Network. HOW TO OBTAIN AUTHORISATION FOR
ASSOCIATED TREATMENT
WHY IS IT NECESSARY FOR ME TO
1. Surgery/procedures/hospital admissions:
REGISTER ON THE ONCOLOGY BENEFIT
If you need to be admitted to hospital for chemo-
MANAGEMENT PROGRAMME?
Travel
therapy or radiotherapy, please contact the Oncology
By enrolling in the programme, you will qualify for
Management Department directly.
the annual oncology family benefit limit. It will also
ensure that health services related to oncology, such
Emergencies
Surgery or related procedures are covered from the
as your doctor’s consultations, general and specialised hospital benefits and not the oncology benefit, so
radiology and pathology during follow-up visits to the you will need to obtain a pre-authorisation from the
doctor, will be covered from your oncology benefit. By Hospital Pre-authorisation Department.
obtaining authorisation you are also ensuring that
2. Specialised radiology (including PET scans):
Specialists
your treatment is effectively managed within your
available benefits. If you require specialised radiology, such as CT, MRI or
PET scans, you will need an additional authorisation
This benefit forms part of your Hospital and Trauma
from the Oncology Management Department for it
Benefits. It is envisaged that in most cases this limit
Co-payments
to be covered from your oncology benefit.
will be sufficient to cover well-managed costs.
When applying for a specialised radiology authorisation,
If your care plan is not approved, you will not have
the following information is required:
access to the oncology benefit limit, and all your
Members
Retiring
NMAS Member Guide 2021 | 20Get in Touch
• membership number excessive vomiting, or need to be hospitalised for
• dependant number pain control.
The Scheme
• requesting doctor practice number
4. Social worker:
• radiology practice number
An Oncology Social Worker Benefit, subject to the
• codes to be charged and estimated cost
Oncology Benefit limit, for the payment of seven
• reason for the scan sessions with a social worker affiliated to the Nedgroup
Digital
Tools
If you need an authorisation for a PET scan, your doctor Oncology Network in the case of terminal cases.
must complete the PET scan form, which is available
at all PET scan units.
PLEASE NOTE
Contributions
3. Hospice, private nursing and medical admissions: The account claims process and claims queries
If you need services such as home nursing or hospice, are not handled by the Oncology Case Manager.
you need to contact the Hospital Pre-authorisation These queries should be directed to the General
Department. You can also contact this department Enquiries call centre.
The Plans
if you have complications such as dehydration or
Screening
RENAL DIALYSIS AND ORGAN TRANSPLANTS
Health
If you need to undergo renal dialysis or an organ • ICD10 code
transplant, you must submit a care plan. • tariff code
Managed
Managed
Care
A 12-month care plan must be submitted to, and • practice number of doctor or supplier
approved by, the Case Manager. • new treatment requested as well as
approximate costs.
This plan should include the following information:
Everyday
Services
Please submit your care plan to:
• date of diagnosis
Hospital Benefit Management
• the area concerned
Fax: 0860 21 22 23 or 021 466 1913
• any prior surgery or treatment
Chronic
nedgroup.authorisations@medscheme.co.za
& Trauma
Hospital
ACTIVE DISEASE RISK MANAGEMENT PROGRAMME
The Nedgroup Medical Aid Scheme Active Disease Risk Members registered on the programme will have
Management Programme identifies members who are access to a health line to discuss any chronic
Travel
at risk of suffering complications or advancement of conditions confidentially with a health coach, as
their chronic conditions. The programme will assist well as be encouraged to access HealthCloud on the
you to control, manage and monitor your conditions. Member Zone.
Emergencies
With your prior consent, your health coach will work
together with you and your GP. Please note the following
• The health coaches are not able to diagnose or treat
If you have been diagnosed or are at potential risk of health problems over the phone and the advice
developing a chronic condition, you may have access
Specialists
provided does not replace a visit to your doctor.
to our dedicated health coaches who will be on hand
• All information regarding your medical condition will
to advise and provide guidance to you. This will be
be kept strictly confidential.
communicated to you in various ways to provide
support, information and practical advice to better Active Disease Risk Management Department
Co-payments
manage or prevent chronic conditions. Telephone: 0860 106 155
Fax: 0860 106 245
Email: membercare@medscheme.co.za
Members
Retiring
NMAS Member Guide 2021 | 21Get in Touch
The Scheme
Digital
Tools
Contributions
The Plans
8
Screening
Health
BENEFITS:
Managed
EVERYDAY SERVICES
Care
Everyday
Everyday
Services
Services
Chronic
1 x Network GP consultation per beneficiary per year.
HOSPITAL
NETWORK 1 x dentist consultation per beneficiary per year. NEW
& Trauma
Hospital
PLATINUM
ROUTINE MEDICAL
RMB
BENEFIT LIMIT
Benefits are paid at up to 3 x MSR.
Travel
Sub-limits are Other specific benefits are
available for certain covered from the Routine
Member: R25 000
Emergencies
benefits. Medical Benefit (RMB) limit.
Member +1: R42 000
Member +2: R44 600
Member +3: R54 200
RMB
Specialists
This benefit
can also be used
to pay for certain
Once these sub-limits are depleted, the available RMB limit other services, once
Co-payments
can also be used to cover the above benefits. you have used up
those limits.
Once your sub-limits and RMB are depleted,
you will be liable for payment.
Members
Retiring
NMAS Member Guide 2021 | 22Get in Touch
COMPREHENSIVE Use our
ANNUAL PMSA AMOUNT online
The Scheme
(AVAILABLE UPFRONT) calculator!
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. Add up the amounts per beneficiary to
calculate the total available for your family.
Sub-limits are Other specific benefits are covered
Digital
Tools
available for from your Personal Medical
certain benefits. Savings Account (PMSA). If you earn Member: R8 460
R10 000 pm or less Adult: R6 600
Contributions
Child (max 2): R1 884
15% If you earn more Member: R8 637
than R10 000 pm Adult: R6 732
Child (max 2): R1 944
The Plans
Once your sub-limits and/or PMSA (whichever is
applicable to the specific benefit) are depleted, you
will be liable for payment.
Screening
Health
TRADITIONAL
Managed
Benefits are paid at MSR.
Care
Sub-limits are available
Everyday
Everyday
Services
Services
for certain benefits.
Chronic
Once your sub-limits are depleted,
you will be liable for payment.
& Trauma
Hospital
SAVINGS Use our
ANNUAL PMSA AMOUNT online
Travel
(AVAILABLE UPFRONT) calculator!
21.3% of your monthly contribution is allocated to your
PMSA. Benefits with sub-limits are paid at MSR, while
Add up the amounts per beneficiary to
benefits payable from PMSA are covered at cost.
Emergencies
calculate the total available for your family.
Most of the listed benefits are Sub-limits are
covered from your Personal Medical available for
Member: R5 844
Savings Account (PMSA). certain maternity If you earn
benefits only. Adult: R5 031
R10 000 pm or less
Specialists
Child (max 2): R1 785
21.3%
If you earn between Member: R6 378
R10 000 and Adult: R6 258
R20 000 pm Child (max 2): R2 118
Co-payments
Member: R6 468
Once your sub-limits and/or PMSA (whichever is If you earn more
applicable to the specific benefit) are depleted, Adult: R6 348
than R20 000 pm
you will be liable for payment. Child (max 2): R2 145
Members
Retiring
NMAS Member Guide 2021 | 23Get in Touch
PLATINUM COMPREHENSIVE TRADITIONAL SAVINGS
The Scheme
Consultations with General Payable from Covered from Member: R2 795 Covered from
Practitioners and Homeopaths Routine Medical available PMSA. Member +1: R5 165 available PMSA.
Visits, consultations, Benefit limit.
Member +2: R5 640
outpatients, procedures out
Member +3: R6 920
of hospital not covered under
Digital
Hospital and Trauma Benefits
Tools
HOSPITAL NETWORK PLAN: 1 x Network GP consultation per beneficiary per year.
Specialists Benefits Limited to and Subject to referral Subject to referral Subject to
included in above from GP - please see from GP - please referral from GP
Consultations limit. If you want to see a see If you want to - please see If
Contributions
Specialist. see a Specialist. you want to see a
Limited to and Limited to and Specialist.
included in above included in above Limited to and
Consultations limit. Consultations limit. included in above
Consultations
limit.
The Plans
Optical benefits R5 600 per Member: R2 890 Member: R2 890 Covered from
• Eye tests beneficiary Member +1: R4 515 Member +1: R4 515 available PMSA.
• Lenses, contact lenses and Once the limit is Member +2: R4 760 Member +2: R4 760
fittings exhausted, this
Member +3: R5 570 Member +3: R5 570
benefit will be paid
Screening
Eye tests are payable from this
A sub-limit of R1 085
Health
from the Routine A sub-limit
benefit limit.
Medical Benefit per beneficiary applies of R1 085 per
Lenses, contact lenses and to frames for the beneficiary applies
limit.
fittings are paid up to the avail- 2-year cycle starting to frames for the
able sub-limits. 1 January 2021 2-year cycle starting
1 January 2021
Managed
Care
Maternity benefits
• Antenatal visits R8 580 combined R4 655 per family R4 655 per family R4 655 per family
maternity benefit
• Antenatal classes per family R1 715 per family R1 715 per family R1 715 per family
Everyday
Everyday
Services
Services
Once the limit is
exhausted, this
benefit will be paid
from the Routine
Medical Benefit limit.
Chronic
• Ultrasound scans 3 x 2D or 3D scans 3 x 2D scans 3 x 2D scans 3 x 2D scans
per family per family per family per family
• Child Vaccinations At a private clinic:
R6 140 per family
& Trauma
Hospital
per year Medication
cost only, excluding
facility fee or nursing
consultations
• Amniocentesis 1 per beneficiary per Travel
event
Dentistry benefits
• Basic dental services R9 180 per R3 645 per beneficiary R3 645 per Covered from
Emergencies
Removal of teeth and roots, beneficiary per Once the limit is beneficiary available PMSA.
removal of wisdom teeth, year for Basic exceeded, claims Once the limit is
exposure of teeth for ortho- and Advanced will be paid from exceeded, claims
dontic reasons and suturing dentistry. Once the Advanced dentistry will be paid from
of traumatic wounds, diagno- limit is exhausted, limit. Advanced dentistry
sis and treatment of oral and this benefit will limit.
Specialists
associated conditions, plastic be subject to the
dentures. Routine Medical HOSPITAL NETWORK PLAN:
Benefit limit. 1 x dentist consultation per beneficiary per year
NEW
• Advanced dentistry
Inlays, bridgework, crowns Member: R4 865 Member: R4 865 Covered from
excluding gold content,
Co-payments
Member +1: R8 830 Member +1: R8 830 available PMSA.
mounted study models,
metal base partial dentures, Member +2: R9 110 Member +2: R9 110
orthodontics (up to age 21), Member +3: R10 870 Member +3: R10 870
periodontists, prosthodontists
and dental technicians.
Members
Retiring
NMAS Member Guide 2021 | 24You can also read
