MEMBER GUIDE 2020 For additional valuable information, visit our website at nmas.medscheme.com - We are MYMEMBERSHIP
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For additional valuable information, visit
our website at nmas.medscheme.com
2020
MEMBER GUIDE
CONTENTS 1. GET IN TOUCH 4 2. THE SCHEME – THERE FOR YOU 7 3. DIGITAL TOOLS 8 4. 2020 EMPLOYEE CONTRIBUTIONS 9 5. OVERVIEW OF THE FIVE PLANS 10 6. BENEFITS: HEALTH SCREENING 12 7. BENEFITS: MANAGED CARE PROGRAMMES 14 8. BENEFITS: EVERYDAY SERVICES 20 9. BENEFITS: CHRONIC MEDICINE 25 10. BENEFITS: HOSPITAL AND TRAUMA 27 11. BENEFITS: HEALTHCARE COSTS WHILE TRAVELLING 37 12. BENEFITS: EMERGENCY SERVICES 38 13. IF YOU WANT TO SEE A SPECIALIST 41 14. CO-PAYMENTS, PENALTIES AND OUT-OF-POCKET EXPENSES 42 15. INFORMATION FOR RETIREES AND OTHER CONTINUATION MEMBERS 46 16. HOW TO SAVE MONEY AND MAKE THE MOST OF YOUR BENEFITS 47 3 | 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
Contributions
2. When the following menu is read out, choose option 2, “If you are an existing member please
press 2”.
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
The Plans
appropriate menus.
For enquiries about the BENEFITS available to you, MEMBERSHIP, or other GENERAL
QUESTIONS and issues
Screening
Health
• Use NedChat
• Email nedgroup.enquiries@medscheme.co.za (benefit and general enquiries) or
nedgroupregistry@medscheme.co.za (enquiries about membership only)
Managed
• Call 0860 100 080 (or 011 671 6833)
Care
• Fax 0860 111 784/011 758 7041
To submit a CLAIM or follow up on the payment of claims
Everyday
Services
For new claims:
• Scan your account(s) and send via NedChat, or email to nedgroup.newclaims@medscheme.co.za, or
• Fax your accounts to 0860 111 784
Chronic
To follow up on claims:
• View your claims online on the logged-in Member Zone
• Call 0860 100 080
& Trauma
Hospital
• Email nedgroup.enquiries@medscheme.co.za
To get AUTHORISATION for a hospital admission Travel
• Email nedgroup.authorisations@medscheme.co.za
• Call 0860 100 080
• Fax 0860 21 22 23 or 021 466 1913
Emergencies
To check whether your provider is on the GP or Specialist NETWORK, or to find one who is
• Email nedgroup.enquiries@medscheme.co.za
• Call 0860 100 080
Specialists
• Login to the Member Zone to access the provider look-up tool
To check where your closest NETWORK HOSPITAL is (only for members on Hospital
Network Plan):
Co-payments
HOSPITAL
NETWORK • Email nedgroup.enquiries@medscheme.co.za
PLAN
• Call 0860 100 080
• Refer to the Network Hospital list on the website: nmas.medscheme.com
Members
Retiring
NMAS Member Guide 2020 | 4
Get
Get in
in Touch
Touch
In an EMERGENCY, or for the ‘Ask a Nurse’ HELPLINE: Call 084 124
The Scheme
To find out where your nearest Network Pharmacy is for preventative SCREENING TESTS
AND VACCINES
Digital
• Call 0860 100 080
Tools
• Email nedgroup.enquiries@medscheme.co.za
Contributions
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
ScriptPharm Risk Management
• Call 011 100 7557
• Fax 086 679 1579
The Plans
• Email nedgroup@scriptpharm.co.za
• Visit www.scriptpharm.co.za
To obtain a copy of your TREATMENT PLAN, or have it updated
Screening
Health
• Call 0860 100 080
• Email nedgroupapmb@medscheme.co.za
To confirm whether you qualify for the BACK AND NECK REHABILITATION Programme and
Managed
Care
to find your closest DBC Centre
• Call 0860 100 080
• Email nedgroup.enquiries@medscheme.co.za
Everyday
Services
• Visit www.dbcsa.co.za
To contact the ONCOLOGY Management Programme (for CANCER patients)
• Call 0860 100 572
Chronic
• Fax 021 466 2303
• Email cancerinfo@medscheme.co.za
& Trauma
For the HIV and AIDS Management Programme, contact Aid for AIDS
Hospital
• Call 0860 100 646 / 021 466 1700
• Fax 0800 600 773
• Email afa@afadm.co.za
Travel
• Visit www.aidforaids.co.za (or www.aidforaids.mobi on a smartphone)
• SMS (call me) 083 410 9078
Emergencies
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 2020 | 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 Ground Floor, Icon Building, Cnr Lower Long Street and Hans Strijdom Avenue
Durban 102 Stephen Dlamini Road, Musgrave
Digital
Tools
Kathu 6 Rietbok Street
Kimberley Shop 17, Southey Street
Contributions
Klerksdorp Shop 11, Medicover Building, 22 Knowles Street, Witkoppies
Lephalale (Ellisras) Bosveld Boulevard Park, Shop 6, Cnr Chris Hani and Joe Slovo Street, Onverwacht
Mafikeng 1st Floor, East Gallery, Office 101A, Mega City
Nelspruit Union Square Unit G2, 44 Mostert Street
The Plans
Shop 2, Ground Floor, Shoprite Checkers Centre,
Polokwane
Cnr Hans van Rensburg & Grobler treets
Port Elizabeth Block 6, Greenacres Office Park, 2nd Avenue, Newton Park
Screening
Health
Pretoria Nedbank Plaza, Shop 17, Ground Floor, 361 Steve Biko Street, Arcadia
Flora Centre, Entrance 2, Shop 21 & 22, Cnr Ontdekkers and Conrad Road,
Roodepoort
Florida North
Secunda Grand Palace, Unit A2, 2302 Heunis Street
Managed
Care
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
If you are not satisfied with the outcome, you are requested to make use of the following process to contact the
Hospital
specific Medscheme managers of the Scheme via e-mail if not specified otherwise:
Valecia Moodley (Team Leader) valeciam@medscheme.co.za / 011 671 2238
If you are not satisfied,
LEVEL 1 Sunelda Gravett (Team Leader) sundeldag@medscheme.co.za / 011 758 8766
Travel
go to level 2.
Lu Soman (Team Leader) lucindas@medscheme.co.za / 011 671 4326
If you are still not
LEVEL 2 Yasmin Khan (Call Centre Manager) yasmink@medscheme.co.za / 011 671 2783
Emergencies
satisfied, go to level 3.
If you are still not
LEVEL 3 Trevor Bailey (Fund Manager) trevorb@medscheme.co.za / 021 466 1632
satisfied, go to level 4.
If you are still not
LEVEL 4 Felecia Oortman (Assistant Principal Officer) feleciao@nedbank.co.za / 010 234 5595
satisfied, go to level 5.
Specialists
LEVEL 5 Julia Le Roux (Principal Officer) julial@nedbank.co.za / 021 412 3814
If, after following the procedure detailed above, you are still not satisfied with the outcome of the process, or you
Co-payments
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 2020 | 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 of money on marketing to attract new members.
for profit, but simply want to ensure that you and This is just one of the ways in which we save… and
your dependants have great medical cover and the thus pass the savings on to you. In fact, independent
Screening
Health
support 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 2020 | 7
Get in Touch
3 DIGITAL TOOLS
The Scheme
Digital
Digital
Tools
Tools
NEDCHAT
NedChat is our all-in-one live chat app that puts you
Contributions
in one-on-one contact with a scheme representative
– Mondays to Fridays from 8:30 to 17:00.
WHAT CAN YOU DO WITH NEDCHAT?
• Clarify simple enquiries without having to call the
The Plans
Contact Centre or sending emails.
• Ask benefit and/or claims-related questions.
PERSONAL HEALTH RECORD • Attach documentation (even claims) to a
Personal Health Record (PHR) is a simple, easy-to- message and forward it directly to the consultant.
Screening
use facility that gives you and your doctor access to
Health
• Send a photo of any document as an attachment.
your complete health record anywhere, any time… plus
great lifestyle tools to live better. • View an electronic version of your membership card.
You can use it to find information on your condition, HOW TO GET NEDCHAT
Managed
Care
surgical procedures and medication. • Smartphones: The NedChat functionality is
currently available on Android and Apple iOS
YOU CAN ALSO USE IT TO:
platforms. Simply download NedChat free from
• View your medical history including immunisations http://mobile.cellfind.co.za/MobiApp/dl/nedchat,
Everyday
Services
and allergies. or search NedChat via your mobile app store and
• Track your health measurements such as blood start chatting!
pressure results and blood sugar levels. • Desktop computers and laptops: This service is
• Earn reward badges for healthy behaviour. also available to registered users in the logged-in
Chronic
• View your doctor appointments and zone on the NMAS website by clicking on the
hospital admissions. NedChat widget/icon.
• See how healthy you are with a Health
& Trauma
Hospital
Risk Assessment.
• Connect a wearable device and track your activity
and calories burned. SCHEME APP
Use our responsive member app to -
Travel
ACTIVATING PHR:
The Nedgroup Personal Health Record can be activated • access your latest benefit limits,
from both PC and smartphone. • see and update
Emergencies
beneficiary details,
• On PC, you can access the PHR via the logged-in
Member Zone (visit nmas.medscheme.com). • check service provider claims,
• On smartphones, search for Nedgroup PHR in your - and lots more!
app store.
Specialists
Please note: Before you can access your PHR details,
call 0860 100 080 to give consent to activate your GET THE APP
PHR. You can start using your PHR via the logged-in ON YOUR
SMARTPHONE!
Co-payments
Member Zone as soon as it has been activated (usually
within 24 hours of giving consent). You can download our free
Scheme smartphone app
from the Android and
iOS App Stores.
Members
Retiring
Get in Touch
2020 EMPLOYEE
4 CONTRIBUTIONS
The Scheme
Digital
Tools
1 January 2020 - 31 March 2020
VALUE-ADD
(same amounts as from April 2019)
• 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 211 R4 065 R1 248 or mentally disabled and financially
COMPREHENSIVE (includes 15% allocation to PMSA) dependent on you, qualifies for child rates.
The Plans
R0 – R4 500.99 R3 867 R3 016 R851 • A child over age 23 who is financially
R4 501 – R6 000.99 R4 210 R3 283 R941 dependent on you can be registered as
an additional adult dependant.
R6 001 + R4 295 R3 350 R970
Screening
TRADITIONAL
Health
Up to R6 000.99 R3 720 R2 900 R816
R6 001 + R3 793 R2 959 R880
SAVINGS (includes 21.3% allocation to PMSA)
Managed
Care
Up to R6 000.99 R2 075 R1 786 R 634
R6 001 + R2 262 R2 220 R 753
HOSPITAL NETWORK
Everyday
Services
Up to R6 000.99 R1 278 R1 112 R403
R6 001 + R1 587 R1 563 R545 TIP:
Use our handy
Chronic
online calculator
to automatically
1 April 2020 - 31 December 2020 calculate your
family’s monthly
Member Adult Child (max 2)
& Trauma
contributions.
Hospital
PLATINUM
All income levels – monthly R5 680 R4 431 R1 360
COMPREHENSIVE (includes 15% allocation to PMSA)
Travel
Up to R10 000.99 R4 526 R3 529 R1 012
R10 001 + R4 617 R3 601 R1 043
Emergencies
TRADITIONAL
Up to R10 000.99 R3 999 R3 118 R877
R10 001 + R4 077 R3 181 R946
SAVINGS (includes 21.3% allocation to PMSA)
Specialists
Up to R10 000.99 R2 231 R1 920 R682
R10 001 + R2 432 R2 387 R809
HOSPITAL NETWORK
Co-payments
Up to R10 000.99 R1 318 R1 146 R415
R10 001 – R20 000.99 R1 665 R1 640 R 572
Contributions for active employees are based on
R20 001 + R1 698 R1 672 R583 Total Guaranteed Package (TGP).
Members
Retiring
NMAS Member Guide 2020 | 9
Get 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
NEW Hospital Network Plan)
Managed
Care
HOW TO CHOOSE A PLAN
Everyday
Services
Weigh up your needs with what you can afford…
YOUR • How healthy are you and your loved ones? What were your
NEEDS medical expenses during the previous benefit year, and do you
Chronic
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
& Trauma
Hospital
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
Travel
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
YOU CAN
the Plan you select. Before moving to a lower-cost Plan, make sure
AFFORD
that 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 2020 | 10Get in Touch
... BUT
THE PLANS DIFFER MAINLY IN HOW THE
The Scheme
DIFFERENT FOLLOWING ARE COVERED:
Digital
Tools
Everyday services Non-PMB chronic
benefits conditions
Contributions
PLATINUM Covers PMB and approved
Offers the highest benefits, non-PMB conditions from a set
Flexibility for a healthy family with a
paying up to 3 x Medical benefit limit, then from Routine
higher income who wants excellent
The
The plans
Scheme Rate (MSR). Medical Benefit, then covers PMB
cover for everyday services benefits
Plans
unlimited.
such as GP consultations.
Screening
Health
COMPREHENSIVE
Covers certain benefits from
Covers approved non-PMB
Cover for higher healthcare needs, a personal medical savings
conditions from a set benefit
especially chronic conditions, with account, allowing more
limit; PMB conditions unlimited.
Managed
a savings allocation allowing more flexibility.
Care
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
pre-set sub-limits.
especially chronic conditions, with sub- limit; PMB conditions unlimited.
Chronic
limits on everyday services benefits.
SAVINGS
& Trauma
Hospital
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
healthy family who is happy to have
medical savings account. limit, then covers PMB unlimited.
everyday services covered from an
Travel
annual savings allocation.
Emergencies
HOSPITAL NETWORK
If you have no immediate healthcare Restricted cover for everyday
Cover only for PMB conditions
needs, but want the peace of mind of services (1 network GP
and Major Depression.
consultation)
Specialists
having cover mainly for unforeseen
hospital procedures and serious
diseases.
Co-payments
Members
Retiring
NMAS Member Guide 2020 | 11Get in Touch
The Scheme
Digital
Tools
Contributions
The Plans
6
screening
Screening
Health
Health
BENEFITS:
Managed
HEALTH SCREENING
Care
Everyday
Services
Why should I go for screening tests? how to improve your health. Another advantage of
Having screening tests done is one of the most these screening tests is that members with potentially
Chronic
important things you can do for your health. Screenings high risks in terms of their health may be identified
are medical tests that check for diseases before there at an early stage.
are any known symptoms. Screenings can help doctors
You will be covered for the following diagnostic tests
find diseases early, when the diseases may be easier
& Trauma
Hospital
(two sets, or you will have the flexibility to choose to
to treat. Do bear in mind, though, that screening tests
have all the tests at one encounter, either at a health
are only indicative. For a more accurate diagnosis of a
screening event or at a Nedgroup Network Pharmacy,
chronic condition, your doctor may refer you for more
or to have multiple individual tests over the benefit
extensive blood tests to determine whether you require
year, subject to the benefit limit of R345:
Travel
chronic medication. For more information please call
0860 100 080. Measurement of height, weight and
waist circumference
Emergencies
What is available under the Health
Screening Benefits? Body Mass Index calculation
The following Health Screening Benefits are
available to members on ALL Plans: Blood sugar
Specialists
Blood pressure
HEALTH SCREENING TIP:
Cholesterol To book a health
You have access to the Nedgroup Network Pharmacy screening at a pharmacy
Co-payments
Screening Programme, allowing you and your clinic, or for more information
dependants to visit a participating Nedgroup Network about the process, visit
pharmacy clinic or attend a Scheme health screening dischem.co.za/stay-well-clinic
event, so that a qualified nurse can give you advice on for Dis-Chem or
clicks.co.za/clinicBooking
Members
for Clicks Pharmacies.
RetiringGet in Touch
The Scheme
Digital
Tools
If you would
like information
on where you can
Contributions
access the screening All screening
tests, please call tests will be
0860 100 080. covered at the Medical
Scheme Rate (MSR). If
the provider charges more
The Plans
than MSR, the difference
HIV SCREENING will be for your
account.
You also have the following HIV tests and services
VACCINATIONS
screening
Screening
available on all Plans:
Health
Health
• Pre-testing counselling, The following vaccinations are covered under the
• Testing and post-test counselling. Health Screening Benefits:
Managed
Your monthly statement will reflect any claims received • One flu vaccine per beneficiary per benefit year.
Care
and paid once this benefit has been accessed. The • One pneumococcal vaccine per member or beneficiary
claims are paid from your HIV Benefit and not from aged 65 or over every 5 years.
your Everyday Services Benefits.
NEW • One HPV vaccine course per beneficiary aged 9-26.
Everyday
Services
CANCER SCREENING TESTS PLEASE NOTE
ONLY the vaccines are covered under this benefit,
Pap smear (usually performed by a GP or whereas any consultation fees will be paid
Chronic
gynaecologist) – limited to one test per from the Everyday Services Benefits limit (for
female beneficiary per benefit year. applicable Plans) or, in the case of Savings Plan
members with insufficient savings or Hospital
Prostate Specific Antigen (a blood test to
& Trauma
Network Plan members, from the member’s
Hospital
screen for prostate cancer) – limited to one
own pocket.
test per male beneficiary over age 45 per
benefit year.
Mammogram (performed at a radiology OTHER SCREENING TESTS
Travel
practice) – limited to one test per female
beneficiary over age 40 per benefit year. Glaucoma screening (performed at an
optometrist/ophthalmologist) – limited to
Emergencies
Colorectal screening (where a sample of your one test per beneficiary over age 55.
stool is screened by a pathologist) – limited
to one test per beneficiary over age 50 per Bone density screening (performed at a
benefit year. radiology practice) – limited to one test per
beneficiary over age 65 every two years.
Specialists
PLEASE NOTE Your monthly statement will reflect any claims received
ONLY the tests are covered under this benefit; and paid once this benefit has been accessed.
whereas any consulting fees will be paid from the
The claims are paid from your Health Screening
Co-payments
Everyday Services Benefits limit (for applicable
Benefit and not from your Everyday Services Benefits.
Plans) or, in the case of Savings or Hospital
Any medical expenses not covered under the Health
Network Plan members with insufficient savings
Screening Benefit will be paid from your Everyday
in their PMSA, from the member’s own pocket.
Services Benefits.
Members
Retiring
NMAS Member Guide 2020 | 13Get in Touch
The Scheme
Digital
Tools
Contributions
7
The Plans
BENEFITS: MANAGED CARE
Screening
Health
PROGRAMMES
Managed
Managed
Care
In addition to the services and procedures covered under Hospital and Trauma Benefits, you will
Everyday
Services
also receive assistance, support and education on your condition if you register on the following
Managed Care Programmes:
-- Diabetes Management Programme -- HIV and AIDS Management Programme
Chronic
-- GoSmokeFree Programme -- Oncology Benefit Management Programme
-- Back and Neck Rehabilitation Programme -- Active Disease Risk Management Programme
-- Mental Health Programme -- Renal Dialysis and Organ Transplant Programme
& Trauma
Hospital
DIABETES MANAGEMENT PROGRAMME
Travel
The Scheme’s Diabetes Management programme and diabetic educators to allow you to effectively
Emergencies
helps members with diabetes better understand this manage your diabetes.
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
As most diabetics have at least one other chronic you will also enjoy online assistance through the
Specialists
condition, the programme offers a personalised care YourHealth Portal.
plan to ensure that your specific needs are taken into
account. The care plan will provide cover for the tests HOW TO ACCESS THE PROGRAMME
required for the management of diabetes as well For more information, or to register on this programme:
Co-payments
as your other chronic conditions. It offers access to
Call 0860 100 080 or
specialised diabetes doctors, dieticians, podiatrists
Email membercare@medscheme.co.za
Members
Retiring
NMAS Member Guide 2020 | 14Get in Touch
GOSMOKEFREE PROGRAMME
(ALL PLANS EXCEPT HOSPITAL
The Scheme
NETWORK PLAN)
The GoSmokeFree programme is aimed at helping
members who smoke to kick the habit!
Digital
Tools
Studies show that 70% of smokers would like to give up
smoking and 30% go on to attempt to stop each year
… yet fewer than 3% successfully quit cold turkey! It
Contributions
has also become clear that the most effective smoking
cessation intervention is a combination of behaviour
change techniques, medication and support – that Africa using a trained Nursing Sister or Pharmacist,
is why the GoSmokeFree Stop Smoking Programme so access to the programme is easy.
uses all these techniques.
The Plans
HOW WILL THIS BENEFIT BE COVERED?
HOW DOES IT BENEFIT YOU?
• Hospital Network Plan: No benefit
Stopping smoking is the single most important decision
• Savings Plan: Payable from available PMSA
you can make for your health. The benefits of stopping
• Comprehensive, Traditional and Platinum Plans:
Screening
smoking are almost immediate, but stopping smoking
Health
is not easy, as nicotine is highly addictive and smoking Payable from Everyday Services Benefits
is associated with social activities such as drinking or
HOW CAN YOU ACCESS THE BENEFIT?
eating and psychological factors such as work pressure,
Visit www.gosmokefree.co.za to find out more
anxiety and body weight concerns.
Managed
Managed
and to locate your nearest pharmacy.
Care
The GoSmokeFree Stop Smoking Programme is Call 0860 100 080 for more information
available at various pharmacies throughout South
Everyday
Services
BACK AND NECK REHABILITATION PROGRAMME
Chronic
The DBC back and neck rehabilitation programme • Medscheme’s predictive model identifies you as being
consists of up to 12 sessions over a 6-week period. at risk of a back/neck admission in the next year (if
The treatment takes place at specific DBC centres. you haven’t yet visited one of the accredited centres).
& Trauma
Hospital
The DBC Treatment System was developed in Finland As the list of centres is still limited, the Scheme will
more than 20 years ago and today the DBC network only identify and contact members within 30km of a
spans treatment providers in more than 22 countries. DBC centre as we often find that members who have
The DBC system is completely evidence and outcomes to travel more than 30km would decline to enrol on Travel
based with a current global success rate in excess of the Programme.
85% after an average of 3 to 9 weeks’ treatment.
Every centre in the DBC network provides treatment • Your specialist or GP may refer you to participate
in the Programme.
Emergencies
data to DBC Finland and this data is used for quality
control and reporting. • You may self-refer by contacting the Scheme on
0860 100 080, should you experience chronic,
HOW TO ACCESS THE PROGRAMME ongoing back or neck pain.
You can access the programme in various ways.
PROGRAMME VS SURGERY – IMPLICATIONS
Specialists
The Scheme will refer you to the programme if: See the chapter Co-Payments, Penalties and Out-of-
• you request a pre-authorisation for an admission Pocket Expenses for more information.
related to back/neck surgery (for example a spinal
WHERE ARE THE DBC CENTRES?
fusion), pain management (for example a rhizotomy)
Co-payments
or specialised radiology (for example an MRI scan), or There are DBC centres throughout South Africa, with
additional centres opening on an ongoing basis. Please
call 0860 106 155 or visit www.dbcsa.co.za to find the
DBC centre closest to you.
Members
Retiring
NMAS Member Guide 2020 | 15Get 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.
Everyday
of mental health care of these beneficiaries. Parallel to
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
Chronic
provide you with direct access to a care manager
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
& Trauma
Hospital
for enrolment also includes beneficiary consent to your condition.
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 benefit 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 2020 | 16Get in Touch
HIV AND AIDS MANAGEMENT PROGRAMME
The Scheme
Members and dependants of the Nedgroup Medical AFTER YOU HAVE REGISTERED
Aid Scheme have access to benefits for the treatment After you receive the application form, you and your
of HIV and AIDS. These benefits can be accessed doctor must complete it and return it to the HIV
by registering on the HIV and AIDS management and AIDS management programme by using the
Digital
programme and all Nedgroup Medical Aid Scheme
Tools
confidential, toll-free fax line number on the form. A
members are entitled to join. highly qualified medical team will examine your details
and if necessary, discuss an appropriate treatment
HIV/AIDS
with your doctor.
Contributions
For most people HIV/AIDS is a frightening disease, but
today treatment is available that allows the majority Once treatment has been agreed upon, you and your
of people living with HIV to lead healthy and productive doctor will be sent a detailed treatment plan, which
lives for many years. explains the approved medicine as well as the regular
tests that need to be done to ensure that the medicines
The Plans
ACTION AND INFORMATION are working correctly.
The first step is to find out whether you have been
infected with HIV and what you can do to protect your WHAT THE HIV AND AIDS MANAGEMENT
loved ones and stay healthy. Medicines are available PROGRAMME OFFERS YOU
Screening
to attack the virus, while vitamins, good nutrition The Scheme’s HIV and AIDS management programme
Health
and exercise can play a critical role in keeping your is a complete HIV disease management programme
body strong and healthy. Starting treatment at the that offers both members and beneficiaries:
right time ensures the effectiveness of the medicines,
improves quality of life and decreases the risk of serious • Medicine to treat HIV (including drugs to prevent
Managed
Managed
mother-to-child transmission and infection after
Care
infections or other complications. Our HIV and AIDS
sexual assault or needle stick injury) at the most
management programme can help you access benefits
appropriate time.
to assist you with the best way of managing HIV/AIDS.
• Treatment to prevent opportunistic infections like
WE CAN HELP YOU TO MANAGE YOUR CONDITION
Everyday
Services
certain serious pneumonias and tuberculosis.
Our HIV and AIDS management programme is
• Regular monitoring of disease progression and
specifically for HIV/AIDS related medicine. This
response to therapy.
programme is used to pay for medicine to attack
• Regular monitoring tests to pick up possible side-
Chronic
the virus, vitamins to boost your immune system and
regular monitoring tests. effects of treatment.
• Ongoing patient support via a Treatment
YOUR CONDITION WILL STAY CONFIDENTIAL
Support Line.
& Trauma
HIV is a sensitive matter and every effort is made to
Hospital
keep your condition confidential. The staff members • Clinical guidelines and telephonic support for doctors.
have all signed confidentiality agreements and are • Help in finding a registered counsellor for
employed in a separate company from the Scheme emotional support.
or the administrator. Staff who manage the HIV and
Travel
Managed by Aid for AIDS (AfA) Pharmacy
AIDS management programme will not reveal your Direct and Clicks
HIV status to anyone without your permission. The Tel: 0860 100 646 Pharmacy are
HIV and AIDS management programme uses separate
Emergencies
now the Designated
telephone, fax and private mailbag facilities from the Fax: 0800 60 0773
Service Providers for
Scheme or the administrator. Patients need to use HIV medication.
Email: afa@afadm.co.za
these facilities to maintain confidentiality. See page 26.
Website: www.aidforaids.co.za
YOU MUST REGISTER ON OUR HIV AND AIDS
Specialists
MANAGEMENT PROGRAMME Mobisite: www.aidforaids.mobi
If your test shows you are HIV-positive you must register
SMS (call me): 083 410 9078
on the HIV and AIDS management programme as soon
as possible to make use of this benefit. Telephone in
Co-payments
confidence and ask for an application form and the The HIV/AIDS Care Manager will assist with all your
counsellor will also assist you with registering on the questions regarding the condition, its treatment, social
HIV and AIDS management programme. Your doctor issues or any concerns that you may have.
can also contact us on your behalf.
Members
Retiring
NMAS Member Guide 2020 | 17Get in Touch
ONCOLOGY BENEFIT MANAGEMENT PROGRAMME
(FOR CANCER PATIENTS)
The Scheme
If you are diagnosed with cancer, it will be to your If your care plan is not approved, you will not have
advantage to contact the Oncology Case Manager access to the oncology benefit limit, and all your cancer-
before starting any treatment. The Oncology Benefit related accounts will be paid from your Everyday
Management Programme will not only help you to Services Benefits.
Digital
Tools
manage the high costs associated with treatment,
but you will also receive help, support and education The Oncology Case Manager will address any concerns
on your condition from the Oncology Case Manager. with the treating oncologist.
Contributions
The Scheme has appointed the Nedgroup Oncology • Please submit your care plan to
cancerinfo@medscheme.co.za.
Network as our Designated Service Provider for
oncology. If you are referred to a provider for If you have any queries regarding the Oncology Benefit
oncology-related treatment, please check with your Management Programme or your condition, please
administrator whether the provider is part of the
The Plans
contact the Oncology Case Manager on 0860 100 572.
Nedgroup Oncology Network.
HOW TO OBTAIN AUTHORISATION FOR
WHY IS IT NECESSARY FOR ME TO ASSOCIATED TREATMENT
REGISTER ON THE ONCOLOGY BENEFIT
1. Surgery/procedures/hospital admissions:
Screening
MANAGEMENT PROGRAMME?
Health
If you need to be admitted to hospital for chemo-
By enrolling in the programme, you will qualify for
therapy or radiotherapy, please contact the Oncology
the annual oncology family benefit limit. It will also
Management Department directly.
ensure that health services related to oncology, such
Managed
Managed
as your doctor’s consultations, general and specialised Surgery or related procedures are covered from the
Care
radiology and pathology during follow-up visits to the hospital benefits and not the oncology benefit, so
doctor, will be covered from your oncology benefit. By you will need to obtain a pre-authorisation from the
obtaining authorisation you are also ensuring that Hospital Pre-authorisation Department.
your treatment is effectively managed within your
Everyday
Services
available benefits. 2. Specialised radiology (including PET scans):
If you require specialised radiology, such as CT, MRI or
This benefit forms part of your Hospital and Trauma
PET scans, you will need an additional authorisation
Benefits. It is envisaged that in most cases this limit
from the Oncology Management Department for it
Chronic
will be sufficient to cover well-managed costs.
to be covered from your oncology benefit.
When applying for a specialised radiology authorisation,
the following information is required:
& Trauma
Hospital
UPGRADE TO
ACCESS ENHANCED • membership number
BENEFITS • dependant number
If you or one of your dependants • requesting doctor practice number Travel
are diagnosed with cancer or have to • radiology practice number
undergo oncology treatment and your • codes to be charged and estimated cost
Plan does not provide adequately for
• reason for the scan
Emergencies
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
diagnosis of cancer, or having
Specialists
had to undergo oncology
treatment.
Co-payments
Members
Retiring
NMAS Member Guide 2020 | 18Get in Touch
If you need an authorisation for a PET scan, your doctor 4. Social worker:
must complete the PET scan form, which is available An Oncology Social Worker Benefit, subject to the
The Scheme
at all PET scan units. Oncology Benefit limit, for the payment of seven
sessions with a social worker affiliated to the Nedgroup
3. Hospice, private nursing and medical admissions:
Oncology Network in the case of terminal cases.
If you need services such as home nursing or hospice,
you need to contact the Hospital Pre-authorisation
Digital
Tools
Department. You can also contact this department PLEASE NOTE
if you have complications such as dehydration or The account claims process and claims queries
excessive vomiting, or need to be hospitalised for are not handled by the Oncology Case Manager.
Contributions
pain control. These queries should be directed to the General
Enquiries call centre.
The Plans
ACTIVE DISEASE RISK MANAGEMENT PROGRAMME
The Nedgroup Medical Aid Scheme Active Disease Risk encouraged to access the YourHealth Portal on the
Screening
Health
Management Programme identifies members who are Member Zone. This is an online educational web and
at risk of suffering complications or advancement of mobile health portal that gives members access to a
their chronic conditions. The programme will assist range of resources to assist with better health choices
you to control, manage and monitor your conditions. which includes e-tutorials and educational articles,
Managed
Managed
With your prior consent, your health coach will work tools and quizzes.
Care
together with you and your GP.
Please note the following
If you have been diagnosed or are at potential risk of • The health coaches are not able to diagnose or treat
developing a chronic condition, you may have access health problems over the phone and the advice
Everyday
Services
to our dedicated health coaches who will be on hand provided does not replace a visit to your doctor.
to advise and provide guidance to you. This will be
• All information regarding your medical condition will
communicated to you by various ways to provide
be kept strictly confidential.
support, information and practical advice to better
Chronic
manage or prevent chronic conditions. Active Disease Risk Management Department
Members registered on the programme will have Telephone: 0860 106 155
access to a health line to discuss any chronic conditions Fax: 0860 106 245
& Trauma
Hospital
confidentially with a health coach, as well as be Email: membercare@medscheme.co.za
Travel
RENAL DIALYSIS AND ORGAN TRANSPLANTS
Emergencies
If you need to undergo renal dialysis or an organ • ICD10 code
transplant, you must submit a care plan. • tariff code
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
Specialists
approximate costs.
This plan should include the following information:
Please submit your care plan to:
• date of diagnosis
Hospital Benefit Management
Co-payments
• the area concerned
Fax: 0860 21 22 23 or 021 466 1913
• any prior surgery or treatment
nedgroup.authorisations@medscheme.co.za
Members
Retiring
NMAS Member Guide 2020 | 19Get in Touch
The Scheme
Digital
Tools
Contributions
The Plans
8
Screening
Health
BENEFITS:
EVERYDAY SERVICES
Managed
Care
Everyday
Everyday
Services
Services
HOSPITAL NETWORK 1 x Network GP consultation per beneficiary per year. NEW
Chronic
& 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: R20 450
benefits. Medical Benefit (RMB) limit.
Emergencies
Member +1: R34 380
Member +2: R36 450
Member +3: R44 300
RMB
This benefit can
Specialists
also be used to
pay for certain other
Once these sub-limits are depleted, the available RMB limit services, once you
can also be used to cover the above benefits. have used up those
Co-payments
limits.
Once your sub-limits and RMB are depleted,
you will be liable for payment.
Members
Retiring
NMAS Member Guide 2020 | 20Get 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 If you earn Member: R7 842
certain benefits. Savings Account (PMSA). R4 500 pm or less Adult: R6 117
Child (max 2): R1 740
Contributions
If you earn Member: R7 995
15% between R4 500 Adult: R6 237
and R6 000 pm Child (max 2): R1 782
If you earn Member: R8 034
between R6 001 Adult: R6 267
and R10 000 pm Child (max 2): R1 794
The Plans
Once your sub-limits and/or PMSA (whichever is
If you earn more Member: R8 160
applicable to the specific benefit) are depleted, you
than R10 001 pm Adult: R6 366
will be liable for payment. from April 2020 Child (max 2): R1 839
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
Travel
ANNUAL PMSA AMOUNT online
21.3% of your monthly contribution is allocated to your calculator!
(AVAILABLE UPFRONT)
PMSA. Benefits with sub-limits are paid at MSR, while
benefits payable from PMSA are covered at cost.
Emergencies
Add up the amounts per beneficiary to
Most of the listed benefits are Sub-limits are calculate the total available for your family.
covered from your Personal Medical available for
Savings Account (PMSA). certain maternity If you earn Member: R5 598
benefits only. R6 000 pm or less Adult: R4 812
Specialists
Child (max 2): R1 710
21.3%
If you earn Member: R5 718
between R6 001 Adult: R5 088
and R10 000 pm Child (max 2): R1 785
Co-payments
If you earn more Member: R6 105
Once your sub-limits and/or PMSA (whichever is than R10 001 pm Adult: R5 988
applicable to the specific benefit) are depleted, from April 2020 Child (max 2): R2 028
you will be liable for payment.
Members
Retiring
NMAS Member Guide 2020 | 21Get in Touch
PLATINUM COMPREHENSIVE TRADITIONAL SAVINGS
The Scheme
Consultations with General Payable from Covered from Member: R2 750 Covered from
Practitioners and Homeopaths Routine Medical available PMSA. Member +1: R4 995 available PMSA.
Visits, consultations, Benefit limit.
Member +2: R5 450
outpatients, procedures out
Member +3: R6 690
of hospital not covered under
Digital
Hospital and Trauma Benefits HOSPITAL NETWORK PLAN: 1 x Network GP consultation per beneficiary per year. NEW
Tools
Specialists Benefits Subject to referral Subject to referral Subject to referral Subject to
from GP - please from GP - please see from GP - please referral from GP
see If you want to If you want to see a see If you want to - please see If
Contributions
see a Specialist. Specialist. see a Specialist. you want to see a
Limited to and Limited to and Limited to and Specialist.
included in above included in above included in above Limited to and
Consultations limit. Consultations limit. Consultations limit. included in above
Consultations
limit.
The Plans
Optical benefits R5 420 per Member: R2 795 Member: R2 795 Covered from
• Eye tests beneficiary Member +1: R4 365 Member +1: R4 365 available PMSA.
• Lenses, contact lenses and Once the limit is Member +2: R4 605 Member +2: R4 605
fittings exhausted, this
Member +3: R5 390 Member +3: R5 390
benefit will be paid
Screening
Eye tests are payable from this
A sub-limit of R1 050
Health
from the Routine A sub-limit of
benefit limit.
Medical Benefit per beneficiary applies R1 050 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. Jan 2019 2-year cycle starting
Jan 2019
Managed
Care
Maternity benefits
• Antenatal visits R8 300 combined R4 500 per family R4 500 per family R4 500 per
maternity benefit family
• Antenatal classes per family R1 660 per family R1 660 per family R1 660 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:
R5 940 per family
& Trauma
Hospital
per year Medication
cost only, excluding
facility fee or nursing
consultations
• Amniocentesis NEW 1 per beneficiary per Travel
year
Dentistry benefits
• Basic dental services R8 880 per R3 525 per beneficiary R3 525 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
Benefit limit.
• Advanced dentistry Member: R4 705 Member: R4 705 Covered from
Inlays, bridgework, crowns Member +1: R8 540 Member +1: R8 540 available PMSA.
excluding gold content,
Co-payments
Member +2: R8 810 Member +2: R8 810
mounted study models,
metal base partial dentures, Member +3: R10 510 Member +3: R10 510
orthodontics (up to age 21),
periodontists, prosthodontists
and dental technicians.
Members
Retiring
NMAS Member Guide 2020 | 22Get in Touch
PLATINUM COMPREHENSIVE TRADITIONAL SAVINGS
The Scheme
Medicines:
• Prescribed medicine (acute) Payable from Covered from Member: R3 705 Covered from
Routine Medical available PMSA. Member +1: R5 770 available PMSA.
• Antenatal vitamins prescribed Benefit limit. Paid at Medicine Price Member +2: R6 090
during pregnancy – excluding or Medicine Price List,
Member +3: R7 130
Digital
Tools
calcium supplements and whichever is the lesser.
Omega preparations Paid at Medicine
Price or Medicine
Price List, whichever
is the lesser.
Contributions
• Pharmacy advised therapy Payable from Covered from R1 475 per Covered from
(PAT) - Medicines supplied by a Routine Medical available PMSA. family, subject available PMSA.
registered pharmacist without Benefit limit. to the prescribed
a prescription from a medical medicine limit.
practitioner or dentist. Benefit
excludes the pharmacy’s
The Plans
administration fee.
The funding of compound anal-
gesics, for example, Myprodol®,
Stilpane® and Syndol® will be
restricted to a maximum
Screening
Health
supply of one hundred tablets
or capsules per year. If your
condition requires medica-
tion in excess of this limit, you,
your doctor or pharmacist
Managed
can contact the Scheme on
Care
0860 100 080. He/she will be
transferred to a clinical agent
who will consider a verbal
motivation.
Everyday
Everyday
Services
Pathology Payable from Member: R2 225 Member: R2 225 Covered from
Services
DSPs (Ampath, Lancet, PathCare, Routine Medical Member +1: R2 830 Member +1: R2 830 available PMSA.
Vermaak & Partners) paid at Benefit limit.
Member +2: R2 875 Member +2: R2 875
cost; non-DSPs paid at Medical
Member +3: R3 155 Member +3: R3 155
Scheme Rate.
Chronic
Radiology (X-rays) Payable from
Covered from
Routine Medical R2 965 per family R2 965 per family
available PMSA.
Benefit limit.
Supplementary health services Payable from Covered from Member: R2 190 Covered from
& Trauma
Hospital
20 practice areas includ- Routine Medical available PMSA. Member +1: R4 045 available PMSA.
ing anthroscopical treatment, Benefit limit.
Member +2: R4 410
applied kinesiology, audiometry,
Member +3: R5 410
audiology, autologous donation
of blood, biokinetics, chiropody,
Travel
chiropractic services, clinical
technology, dieticians, genetic
counselling, hearing aid acous-
tics, naturopaths, occupational
Emergencies
therapy, orthoptic treatment,
podiatry, private nurses, remedial
therapy, speech therapists, and
social workers
Physiotherapy Payable from Covered from R3 510 per family Covered from
Specialists
Physiotherapy following hospi- Routine Medical available PMSA. available PMSA.
talisation is covered under the Benefit limit.
Hospital and Trauma Benefits,
provided it is pre-authorised by
the Case Manager before dis-
Co-payments
charge from hospital.
Members
Retiring
NMAS Member Guide 2019 | 23Get in Touch
PLATINUM COMPREHENSIVE TRADITIONAL SAVINGS
The Scheme
Psychology Payable from R6 580 per family R6 580 per family Covered from
There is a difference in the benefits Routine Medical available PMSA.
you receive for treatment by a Benefit limit.
psychiatrist and a psychologist. A
psychiatrist is a medical specialist
Digital
who may use psychotherapy
Tools
as well as medication to treat
patients. The consultation or
treatment by a psychiatrist will
be deducted from the General
Contributions
Practitioners and Specialists limit,
where applicable. Psychotherapy
by a clinical psychologist, who is
not a specialist, will be deducted
from the Psychology limit, where
applicable.
The Plans
Medical appliances Payable from R4 600 per family R4 600 per family Covered from
Not forming an integral part of Routine Medical available PMSA.
an operation, for example, bau- Benefit limit.
manometer, all orthopaedic
braces, and crutches, as well as
Screening
Health
CPAP equipment. Maintenance
and repairs are not covered by
the Scheme, unless a full quote
is received and pre-authorised
by the Scheme. Approval for
moulded insoles is subject to moti-
Managed
Care
vation from a relevant specialist.
The frequency of the benefit will
be subject to the Scheme’s clinical
protocols.
Everyday
Everyday
Services
Services
Wheelchair and associated R13 120 per family R13 120 per family R13 120 per family Covered from
appliances available PMSA.
Can be purchased or hired, if
approved before acquisition.
Chronic
Hearing aids Payable from R36 560 per family for R36 560 per family Covered from
This benefit covers the cost of the Routine Medical beneficiaries 6 years for beneficiaries 6 available PMSA.
repair of the devices, subject to Benefit limit. and younger years and younger
the quote being submitted to the R25 010 per family for R25 010 per family
Scheme and being approved. A beneficiaries 7 years for beneficiaries 7
& Trauma
Hospital
registered provider must submit and older years and older
the claim. Benefit available per Benefit available per
The cost of batteries is excluded. beneficiary every beneficiary every
2 years, starting 2 years, starting
1 January 2019. 1 January 2019.
Travel
Oral Contraceptives R3 410 per Covered from Payable from Covered from
Products must be prescribed beneficiary for available PMSA. Prescribed medicine available PMSA.
for contraception and not for the Mirena device, (acute) sub-limit.
Emergencies
the treatment of acne or skin with a R1 890
conditions, unless otherwise sub-limit for oral
specified as per managed care contraceptives,
protocols. subject to managed
care protocols.
The cost of a GP
Specialists
or gynaecologist
consultation will be
covered from the
Routine Medical
Benefit.
Co-payments
Members
Retiring
NMAS Member Guide 2020 | 24You can also read
