Benefit Guide Malcor Medical Aid Scheme
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Malcor Medical Aid Scheme Benefit Guide 2018
Information in this benefit brochure A healthy approach to quality and care 2 Who can join the Malcor Medical Aid Scheme 3 Who may join as your dependant 3 General guidelines on the Malcor Medical Aid Scheme 4 Helping you get the most out of your cover 6 Chronic illness, cancer and HIV cover 8 The Malcor Medical Aid Scheme benefit tables – Plans A, B and C 10 The Malcor Medical Aid Scheme benefit tables – Plan D 17 Medicine benefits 21 Prescribed Minimum Benefits (PMBs) and Designated Service Providers (DSPs) 23 Cover for emergencies 24 Advanced technology and convenience 25 Reporting fraud or malpractice 26 Key information 26 General exclusions 27 Contact us 30 The Council for Medical Schemes 31 1
A healthy approach
to quality and care in 2018
We at the Malcor Medical Aid Scheme work hard to keep This year, the Malcor Medical Aid Scheme continues to
our promise to provide you with the best care at all times. ensure the care and services you receive make a significant
In delivering on this promise, we always need to balance the difference in your life. Please read through your Benefit
cost of healthcare with the benefits we provide to make sure Guide which can be accessed on the homepage of the
that as a member of the Malcor Medical Aid Scheme you website at www.malcormedicalaid.co.za to see what we
continue to enjoy the best care in 2018. have in store for you in 2018.
About this benefit guide
This brochure provides you with a summary of the
This booklet serves as a guide to the Malcor Medical Aid benefits and features of the Malcor Medical Aid
Scheme. It consists of information about your membership Scheme, pending approval from the Council for
and benefits. This Benefit Guide is merely a summary of the Medical Schemes. The Malcor Medical Aid Scheme is
benefits and features of the Malcor Medical Aid Scheme plans a closed Scheme, and is administered by Discovery
and is subject to the Rules of the Malcor Medical Aid Scheme. Health (Pty) Ltd.
The Rules of the Scheme will apply in all circumstances.
This brochure gives you a brief outline of the benefits
Members who require further information should contact
Malcor Medical Aid Scheme offers. This does not
their personnel departments or the Scheme at 0860 100 698.
replace the Scheme Rules. The registered Scheme
Rules are legally binding and always take precedence.
Detailed benefit documents may be obtained from
www.malcormedicalaid.co.za > Find a document
if you are registered as an online user. Please share
this information with your dependants who are your
beneficiary members of the Malcor Medical
Aid Scheme.
2
Who can join the Malcor
Medical Aid Scheme?
The Malcor Medical Aid Scheme is a restricted-access medical
scheme for a number of associated employer groups.
An employer is defined as “any company or organisation that
was previously a subsidiary or an associated company
of Malbak Limited at the time of the latter’s dissolution
in 1996, or has subsequently been acquired by such
companies or organisations”. Employers currently making
use of the Malcor Medical Aid Scheme include, but are not
limited to, Unitrans Automotive, Defy Appliances (Pty) Ltd,
Aspen Holdings (Pty) Ltd and Omnia Holdings Limited.
Membership is available to all employees of approved
employers subject, in certain cases, to the satisfactory
outcome of a medical examination.
Who may join as your
dependant?
• Your spouse or partner in a committed and serious
relationship similar to marriage, including mutual
dependency and both partners living in a shared
and common household.
• Your children can be added as dependants on your health
plan. Your child needs to be financially dependent on you
to qualify for cover as an adult dependant. They may
be students, or are mentally or physically disabled.
• You have 30 days in which to register a new spouse.
We count the 30 days from the date of marriage.
• You have 30 days in which to register a newborn
baby. We count the 30 days from the date of birth.
3
General guidelines
on the Malcor Medical Aid Scheme
• embers and their dependants are entitled to benefits
M • It is recommended that members who are about to
from the date their membership commences as reflected embark on any costly treatment that does not require
on their membership cards. specific pre-authorisation, such as orthodontic treatment,
submit quotations to the Scheme to obtain information
• here are certain limitations and exclusions applicable
T
about the extent to which the Scheme will cover the
to all members. To avoid incurring personal liability for
proposed treatment.
medical treatment, members should, if in any doubt,
refer to the Scheme’s Rules or contact the Scheme for • LAN D members might be required to pre-authorise
P
clarification prior to agreeing to such treatment. all benefits BEFORE consulting with service providers.
You may confirm benefits by calling Enablemed on
• he Scheme is, according to the Medical Schemes Act,
T
0860 002 402.
allowed to apply a Late-Joiner Penalty (LJP) to an applicant
or to the dependant of an applicant who fits the definition • nnual limits are apportioned according to the period
A
of a late-joiner. The LJP fee is a percentage increase in of membership in relation to the benefit year i.e.
a member’s contribution. It is a lifetime penalty that is 1 January to 31 December. Thus your benefit limits will
not be removed, even when members move from one be prorated if you join during the benefit year.
registered South African medical scheme to another.
Four innovative cover plans
Plan A Plan B
A traditional, fully comprehensive plan designed for those A traditional, fully comprehensive plan designed for those
seeking complete healthcare cover seeking decent healthcare cover
Excellent out-of-hospital limits Good out-of-hospital limits
All in-hospital costs are covered at 100% of the Scheme Rate All in-hospital costs are covered at 100% of the Scheme Rate
Plan C Plan D
Low-cost, network option administered by Enablemed
A traditional, fully comprehensive plan designed for those
seeking basic healthcare cover Choice of own GP and access to private hospitals
Limited out-of-hospital cover Chronic medicine is covered as set out in the Prescribed
Minimum Benefit guidelines and includes chronic illnesses
All in-hospital costs are covered at 100% of the Scheme Rate
that are on the Chronic Disease List.
4
Pre-authorisation for hospitalisation Pre-authorisation is also required for
You must call the Malcor Medical Aid Scheme on
the following treatment
0860 100 698 to get pre-authorisation for all your hospital • Chronic renal dialysis
treatment, except in the case of an emergency.
• Oncology and radiotherapy
You will be given an authorisation number if your treatment • Hospice
is approved. In the case of an emergency where you are
• Sterilisation
unable to phone the Malcor Medical Aid Scheme to obtain
authorisation in advance, you or a family member must call • Infertility treatments
the Scheme within three days from the date of admission. • Step-down and rehabilitation facilities in the private sector
If you do not obtain authorisation, the Scheme will not • Specialised dentistry in hospital
pay the claims. • Registered nursing services
• Super antibiotics
• Biologicals
5
Helping you
get the most out
of your cover
Make the full cover choice
We offer members the choice to be covered in full for GPs. These GPs agree to join the Discovery Health GP
hospitalisation, specialists (in-hospital), chronic medicine and Network to which you have access.
GP consultations. Look out for the Full Cover Choice stamp in
We will refer to the networks and payment arrangements
this benefit guide. It shows you when to use our range
throughout the Benefit Guide.
of online tools that guide you to full cover.
Remember that your claims are still subject to the overall
annual limit. We have payment arrangements with certain
Members on the Malcor Medical Aid Scheme
may have a co–payment for in- and out-of-hospital
specialist cover
If you are treated by a specialist out-of-hospital, the Malcor hospital network specialist at a Mediclinic hospital for full
Medical Aid Scheme will cover up to 100% of the Scheme cover. The Malcor Medical Aid Scheme will cover up to 100%
Rate. Please log in to the Malcor Medical Aid Scheme website of the Scheme Rate if you are treated by a specialist in-
website at www.malcormedicalaid.co.za > Doctor visits hospital, who is not part of the network.
> Find a healthcare professional to find your nearest in-
6
When you need to go to the doctor
Our Medical and Provider Search Advisor (MaPS) tool helps Log in to www.malcormedicalaid.co.za and click on Doctor
you find a healthcare professional with whom we have an visits > Find a healthcare professional. You will be able to
agreement. These healthcare professionals have agreed to search for providers by geographical location or speciality.
only charge you the Scheme Rate and we pay them in full. Each provider shown on the MaPS tool is shown with a tag
to indicate whether or not they are a network doctor.
GP network doctors are paid directly in full
When you see a GP in the GP Network, their consultation cost Please log in to the Malcor Medical Aid Scheme website
will be paid in full. If you choose to use a GP that is not in the at www.malcormedicalaid.co.za > Doctor visits >
network, the Scheme will reimburse your consultation at the Find a healthcare professional to find your nearest
Scheme Rate. participating GP.
Cover for specialists
The Malcor Medical Aid Scheme offers members access procedures and in-hospital consultations. Remember, we
to an in-hospital Specialist Network at Mediclinic hospitals. fund claims up to the overall annual limit, except in the case
The Malcor Medical Aid Scheme will cover claims for in- of Prescribed Minimum Benefits where we fund them in full.
hospital network specialists in full for their approved
Cover for going to casualty
If you are admitted to hospital from casualty, we will cover the Scheme will pay the claims from your out-of-hospital
the costs of the casualty visit from your Hospital Benefit, benefits. Some casualties charge a facility fee, which we
as long as we confirm your admission. If you go to a casualty do not cover.
or emergency room and you are not admitted to hospital,
7
Chronic illness Cancer
and HIV cover
Cover for chronic medicines
The following guidelines apply to chronic medication
covered by the Scheme
The Chronic Illness Benefit covers approved medicine for
the 27 Prescribed Minimum Benefit (PMB) Chronic Disease
List (CDL) conditions, including HIV and AIDS. The Scheme
will fund approved medicine on the medicine list (formulary)
or medicine in the same medicine class as the approved
medicine up to the Maximum Medical Aid Price (MMAP).
Medicine not on the medicine list will be funded from the
Acute Medicine limit or by yourself.
If your condition is approved by the Chronic Illness Benefit,
it will cover certain procedures, tests and consultations for
the diagnosis and ongoing management of the 27 Prescribed
Minimum Benefits (PMBs) CDL conditions (including HIV and
AIDS) in line with Prescribed Minimum Benefits.
Chronic disease list conditions (all plans)
All members qualify for chronic medication for the
following 27 conditions on the Chronic Disease List (CDL)
that the Medical Schemes Act (No 131 of 1998) defines as
Prescribed Minimum Benefits:
• Addison’s Disease • Dysrythmia
• Asthma • Epilepsy
• Bipolar Mood Disorder • Glaucoma
• Bronchiectasis • Haemophilia
• Cardiac Failure • HIV/AIDS
• Cardiomyopathy • Hyperlipidaemia
• Chronic Obstructive • Hypertension
Pulmonary Disease • Hypothyroidism
• Chronic Renal Disease • Multiple Sclerosis
• Coronary Artery Disease • Parkinson’s Disease
• Crohn’s Disease • Rheumatoid Arthritis
• Diabetes Insipidus • Schizophrenia
• Diabetes Mellitus • Systemic Lupus
Type 1 Erythematosus
• Diabetes Mellitus • Ulcerative Colitis
Type 2
There are further Additional Disease List conditions
that are covered for members on Malcor Plan A.
The Scheme will fund approved medicines for
these conditions up to the Maximum Medical Aid
Price (MMAP).
8
Additional Disease List (ADL) available to Plan A members only
• Acne • Motor Neurone Disease
• Allergic Rhinitis • Myasthenia Gravis
• Ankylosing Spondylitis • Narcolepsy
• Arthritis • Obsessive Compulsive Disorder
• Attention Deficit and Hyperactivity Disorder (ADHD) • Osteoarthritis
• Barret’s Oesophagus • Osteoporosis
• Chronic Hepatitis • Paget’s Disease
• Cystic Fibrosis • Psoriasis
• Depression • Psoriatic Arthritis
• Gastro-oesophageal Reflux Disease
You must apply for chronic cover by completing a Chronic treatment plan and benefits. Members or dependants who
Illness Benefit application form with your doctor and are HIV positive but have not yet enrolled are encouraged
submit it for review. The application form is available to do so. Your health and medical treatment are of the
at www.malcormedicalaid.co.za > Find a document. utmost importance.
Alternatively you can call 0860 100 698 or your healthcare
professional can call 0860 44 55 66 for assistance. For a Cover for HIV prophylactics
condition to be covered from the Chronic Illness Benefit,
there are certain benefit entry criteria that the member If you, as a Malcor member, need HIV prophylactics
needs to meet. If necessary, you or your doctor may to prevent HIV infection from mother-to-child transmission,
have to supply extra motivation or copies of certain occupational and traumatic exposure to HIV or sexual assault,
documents to finalise your application. If you leave out please call Malcor Medical Aid Scheme immediately on 0860
any information or do not provide the medical tests or 100 698 as treatment must start as soon as possible.
documents needed with the application, cover will only This treatment is paid for by the Malcor Medical Aid Scheme
start from when we receive the outstanding information. in full.
Chronic medication DSP Blood transfusions
Dis-Chem has been appointed as the Scheme’s designated Blood transfusions are covered at 100% of the Scheme Rate.
service provider (DSP) for all chronic medicine requirements.
Dis-Chem has offered the Scheme a beneficial dispensing
Oncology programme
fee structure. All chronic medicine is to be obtained from
Dis-Chem. Should members choose to obtain their chronic If you are diagnosed with cancer, you must register
medication from a provider who is unable to match this on the Malcor Medical Aid Scheme’s Oncology Programme.
dispensing fee arrangement, then the member may be liable The Malcor Medical Aid Scheme’s Oncology Programme
for any co-payments. follows the ICON protocols and guidelines.
Please register by calling 0860 100 698.
HIVCare Programme
For members living with HIV and AIDS, the HIVCare Advanced illness benefit
Programme provides comprehensive disease management.
Members with cancer have access to a comprehensive quality
We take the utmost care to protect the right to privacy and
care programme. This programme offers unlimited cover for
confidentiality of our members.
approved care at home.
Malcor members are encouraged to enrol in the HIVCare
Programme by calling the Malcor Medical Aid Scheme
on 0860 100 698. Benefit tip:
The case managers will assist you and guide you with your
Call 0860 100 698 to confirm your cover for
these benefits.
9The Malcor Medical Aid Scheme benefit tables
Hospital benefits: Plans A, B and C
Benefit limits are prorated if a member joins the Malcor Medical Aid Scheme during the year unless otherwise stated.
Pre-authorisation required, except in the case of an emergency.
PLAN A PLAN B PLAN C
Healthcare Service Basis of Cover Annual Limits Annual Limits Annual Limits
Statutory Prescribed Services rendered by public hospitals/DSP at 100% Unlimited Unlimited Unlimited
Minimum Benefits of cost or 100% of the Scheme Rate in a private
hospital where the beneficiary voluntarily elects
another service provider
Where PMB performed in a private hospital
involuntarily such procedure will be paid
at 100% of cost
All Prescribed Minimum Benefits are paid
at cost, subject to requirements as set out
in the Scheme Rules
Overall annual limit for 100% of the Scheme Rate funded from overall Unlimited R1 200 000 per R1 000 000 per
in-hospital expenses annual in-hospital benefit family per annum family per annum
Pre-authorisation required
Accommodation, materials, 100% of the Scheme Rate funded from overall Unlimited Overall annual Overall annual
theatre fees annual in-hospital benefit in-hospital limit in-hospital limit
Pre-authorisation required
Blood transfusions 100% of the Scheme Rate funded from overall Unlimited Overall annual Overall annual
annual in-hospital benefit in-hospital limit in-hospital limit
Ambulance (local 100% of the Scheme Rate funded from overall Unlimited Overall annual Overall annual
emergency evacuation) annual in-hospital benefit in-hospital limit in-hospital limit
DSP applies
Specialists 100% of the Scheme Rate funded from overall Unlimited Overall annual Overall annual
annual in-hospital benefit in-hospital limit in-hospital limit
Specialist Network applies as DSP
Pre-authorisation required
GP 100% of the Scheme Rate funded from overall Unlimited Overall annual Overall annual
annual in-hospital benefit in-hospital limit in-hospital limit
GP Network applies as DSP
Pre-authorisation required
Organ transplants 100% of the Scheme Rate funded from overall Unlimited Overall annual Overall annual
annual in-hospital benefit. PMB at cost in-hospital limit in-hospital limit
Pre-authorisation required
Internal prosthesis 100% of the Scheme Rate funded from overall R100 000 per R70 000 per R35 000 per
(hip, knee, shoulder annual in-hospital benefit beneficiary per beneficiary per beneficiary per
joints,artificial eyes, Pre-authorisation required annum annum annum
intraocular lenses,
defibrillators, pacemakers, Sub-limits: No sub-limits.
stents, spinal items, etc.) Hip R50 000 R35 000 Subject to overall
Knee R50 000 R35 000 internal prothesis
Pacemakers R50 000 R35 000 limit.
Stents R20 000 R20 000
Cardiac stents 100% of the Scheme Rate funded from overall 3 stents per 3 stents per 3 stents per
(limited to the internal annual in-hospital benefit beneficiary per beneficiary per beneficiary per
prosthesis sub-limit for Pre-authorisation required annum annum annum
stents for Plan A and Plan B.
For Plan C it is subject to the
internal prosthesis sub-limit)
Bone-anchored 100% of the Scheme Rate funded from overall Subject to internal Subject to internal Subject to internal
hearing aid annual in-hospital benefit prosthesis limit prosthesis limit prosthesis limit
Pre-authorisation required
10PLAN A PLAN B PLAN C
Healthcare Service Basis of Cover Annual Limits Annual Limits Annual Limits
Spinal prosthesis 100% of the Scheme Rate funded from overall Subject to internal Subject to internal Subject to internal
annual in-hospital benefit prosthesis limit prosthesis limit prosthesis limit
Pre-authorisation required
External medical items 100% of the Scheme Rate funded from overall Unlimited Overall annual Overall annual
(HALO traction, embolytic annual in-hospital benefit in-hospital limit in-hospital limit
stockings, certain back Pre-authorisation required
braces)
Pathology 100% of the Scheme Rate funded from overall Unlimited Overall annual Overall annual
annual in-hospital benefit in-hospital limit in-hospital limit
Pre-authorisation required
Radiology 100% of the Scheme Rate funded from overall Unlimited Overall annual Overall annual
annual in-hospital benefit in-hospital limit in-hospital limit
Pre-authorisation required
Endoscopies 100% of the Scheme Rate funded from overall Unlimited Overall annual Overall annual
annual in-hospital benefit in-hospital limit in-hospital limit
Pre-authorisation required
Specialised radiology 100% of the Scheme Rate funded from overall Unlimited Overall annual Overall annual
(MRI, CT scans, PET scans, annual in-hospital benefit regardless of setting in-hospital limit in-hospital limit
nuclear medicine studies, (out-of-hospital or in-hospital)
angiograms, arthrograms) Pre-authorisation required
Dentistry (maxilla-facial 100% of the Scheme Rate funded from overall Unlimited Overall annual Overall annual
procedures) annual in-hospital benefit in-hospital limit in-hospital limit
Pre-authorisation required
Conservative dentistry and specialised dentistry
not covered in-hospital unless pre-authorised
Ophthalmologic 100% of the Scheme Rate funded from overall Unlimited Overall annual Overall annual
procedures (corneal annual in-hospital benefit in-hospital limit in-hospital limit
crosslinking included) Pre-authorisation required
Mental health 100% of the Scheme Rate funded from overall 21 days per 21 days per 21 days per
annual in-hospital benefit beneficiary per beneficiary per beneficiary per
Pre-authorisation required annum annum annum
Drug and alcohol 100% of the Scheme Rate funded from overall 21 days per 21 days per 21 days per
rehabilitation annual in-hospital benefit beneficiary per beneficiary per beneficiary per
DSP applies annum annum annum
Pre-authorisation required
Detoxification for 100% of the Scheme Rate funded from overall Three days per Three days per Three days per
substance dependency annual in-hospital benefit beneficiary per beneficiary per beneficiary per
DSP applies approved event approved event approved event
Pre-authorisation required
Allied professionals 100% of the Scheme Rate funded from overall Unlimited Overall annual Overall annual
(acousticians, biokineticists, annual in-hospital benefit in-hospital limit in-hospital limit
chiropractors, dietitians, Pre-authorisation required
nursing providers,
occupational therapists,
physiotherapists,
podiatrists, psychologists,
psychometrics, social
workers, speech and
hearing therapists)
11PLAN A PLAN B PLAN C
Healthcare Service Basis of Cover Annual Limits Annual Limits Annual Limits
Private nursing 100% of the Scheme Rate funded from overall Unlimited Overall annual Overall annual
annual in-hospital benefit in-hospital limit in-hospital limit
Pre-authorisation required
Terminal care 100% of the Scheme Rate funded from overall Unlimited Unlimited Unlimited
annual in-hospital benefit. PMB at Cost
DSP applies
Pre-authorisation required
Renal dialysis 100% of the Scheme Rate funded from overall Unlimited Overall annual Overall annual
annual in-hospital benefit in-hospital limit in-hospital limit
DSP applies
Pre-authorisation required
Medication supplied 100% of the Scheme Rate funded from overall Unlimited Overall annual Overall annual
in-hospital annual in-hospital benefit in-hospital limit in-hospital limit
Pre-authorisation required
To-take-out (TTO) 100% of the Scheme Rate funded from overall Overall annual Overall annual Overall annual
medication annual in-hospital benefit in-hospital limit in-hospital limit in-hospital limit
Pre-authorisation required Limited to seven Limited to seven Limited to seven
days days days
International travel 100% of claim funded from the overall annual R500 000 per R500 000 per R500 000 per
in-hospital benefit beneficiary per beneficiary per beneficiary per
Pre-authorisation required journey, 90 days journey, 90 days journey, 90 days
from departure from departure from departure
date date date
Home oxygen 100% of the Scheme Rate funded from overall Unlimited Overall annual Overall annual
annual in-hospital benefit in-hospital limit in-hospital limit
DSP applies
Pre-authorisation required
HIV and AIDS-related 100% of the Scheme Rate funded from Unlimited Overall annual Overall annual
treatment overall-annual in-hospital benefit in-hospital limit in-hospital limit
PMB criteria apply
Post-exposure HIV 100% of cost Unlimited Overall annual Overall annual
prophylaxis following in-hospital limit in-hospital limit
occupational exposure,
traumatic exposure
or sexual assault
HIV prophylaxis to 100% of cost Unlimited Overall annual Overall annual
prevent mother-to-child PMB criteria apply in-hospital limit in-hospital limit
transmission
Prescribed antiretroviral 100% of cost Unlimited Overall annual Overall annual
medication for HIV/AIDS PMB criteria apply in-hospital limit in-hospital limit
and medication to treat
opportunistic infections
such as tuberculosis
and pneumonia
Oncology 100% of the Scheme Rate funded from R500 000 per family R300 000 per family R200 000 per family
the oncology limit per annum per annum per annum
Subject to guidelines and pre-authorisation
by Scheme and ICON
Wigs are covered from the overall out-of-hospital
benefits, subject to the external medical
items limit
Advanced Illness Benefit 100% of the Scheme Rate funded from the overall Unlimited Unlimited Unlimited
(end-of-life care at home for annual in-hospital benefit
members registered on the DSP applies
Oncology Benefit)
Stem cell transplants 100% of the Scheme Rate funded from R500 000 per family R300 000 per family R200 000 per family
overall annual in-hospital benefit per annum (part per annum (part per annum (part
of the Oncology of the Oncology of the Oncology
Benefit) Benefit) Benefit)
12Out-of-hospital benefits: Plans A, B and C
PLAN A PLAN B PLAN C
Healthcare Service Basis of Cover Annual Limits Annual Limits Annual Limits
Overall annual limit for 100% of the Scheme Rate funded from overall R100 000 per family R62 000 per family Annual limit per
out-of-hospital expenses annual out-of-hospital benefit per annum per annum family based
on number of
dependants:
M - R6 885
M1 - R12 390
M2 - R15 145
M3 - R17 885
M4+ - R20 645
GPs and homeopaths 100% of the Scheme Rate funded from overall Overall annual out- Annual limit per Overall annual
annual out-of-hospital benefit of-hospital benefit family based out-of-hospital
DSP for GPs: GP Network limit on number of benefit limit
dependants:
M - 6 visits
M1 - 12 visits
M2 - 16 visits
M3 - 20 visits
M4+ - 24 visits
When the limit is
reached, claims are
funded at 50% of
the Scheme Rate
from the overall
out-of-hospital
benefit.
Specialists (cardiologist, 100% of the Scheme Rate funded from overall Annual limit per Annual limit per Overall annual
paediatrician, gynaecologist, annual out-of-hospital benefit family based family based out-of-hospital
specialist physician, on number of on number of benefit limit
oncologist, etc.) dependants: dependants:
M - 7 visits M - 4 visits
M1 - 12 visits M1 - 8 visits
M2 - 17 visits M2 - 11 visits
M3 - 24 visits M3 - 14 visits
M4+ - 26 visits M4+ - 17 visits
Maternity consultations 100% of the Scheme Rate funded from overall 10 visits per family 6 visits per family Overall annual
(gynaecologist and GPs) annual out-of-hospital benefit per annum per annum out-of-hospital
benefit limit
Endoscopies 100% of the Scheme Rate funded from overall Overall annual out- Overall annual out- Overall annual
annual out-of-hospital benefit if not pre- of-hospital benefit of-hospital benefit out-of-hospital
authorised limit limit benefit limit
External medical items 100% of cost funded from overall annual R3 500 per family R2 330 per family Overall annual
(walking sticks, commodes, out-of-hospital benefit per annum per annum out-of-hospital
bed pans, toilet seat raisers, benefit limit
crutches, glucometers,
foot orthotics and shoe
innersoles, etc)
Walkers 100% of cost funded from overall annual R570 per family per R390 per family per Overall annual
out-of-hospital benefit annum annum out-of-hospital
benefit limit
Wheelchairs (including 100% of cost funded from overall annual R3 430 per family R2 290 per family Overall annual
buggies and carts) out-of-hospital benefit per annum per annum out-of-hospital
benefit limit
Hearing aids 100% of cost funded from overall annual R17 490 per family R11 660 per family Overall annual
out-of-hospital benefit per annum per annum out-of-hospital
benefit limit
Pathology 100% of the Scheme Rate funded from overall Annual limit per Annual limit per Overall annual
annual out-of-hospital benefit. When the limit family based family based out-of-hospital
is reached, claims are funded at 80% of the on number of on number of benefit limit
Scheme Rate from the overall annual out-of- dependants: dependants:
hospital benefit M - R3 030 M - R1 475
M1 - R5 300 M1 - R2 585
M2 - R6 825 M2 - R3 315
M3 - R8 340 M3 - R4 055
M4+ - R9 850 M4+ - R4 790
13PLAN A PLAN B PLAN C
Healthcare Service Basis of Cover Annual Limits Annual Limits Annual Limits
Radiology 100% of the Scheme Rate funded from overall Annual limit per Annual limit per Overall annual
annual out-of-hospital benefit. When the limit family based family based out-of-hospital
is reached, claims are funded at 80% of the on number of on number of benefit limit
Scheme Rate from the overall annual out-of- dependants: dependants:
hospital benefit M - R3 030 M - R1 475
M1 - R5 300 M1 - R2 585
M2 - R6 825 M2 - R3 315
M3 - R8 340 M3 - R4 055
M4+ - R9 850 M4+ - R4 790
Pregnancy scans 100% of the Scheme Rate funded from overall Three scans per Three scans per Three scans per
annual out-of-hospital benefit. When the limit annum annum annum
is reached, claims are funded at 80% of the
Scheme Rate from the overall annual out-of-
hospital benefit
Claims accumulate to the out-of-hospital
radiology limit
Dentistry (conservative 100% of the Scheme Rate funded from overall Annual limit per Annual limit per Overall annual
dentistry and specialised annual out-of-hospital benefit family based family based out-of-hospital
dentistry, inclusive of osseo- on number of on number of benefit limit
integrated implants) dependants: dependants:
M - R9 740 M - R4 470
M1 - R16 225 M1 - R7 450
M2 - R21 100 M2 - R9 680
M3 - R25 980 M3 - R11 910
M4+ - R30 845 M4+ - R12 655
Dental therapy 100% of the Scheme Rate funded from overall R1 195 per family R845 per family per Overall annual
annual out-of-hospital benefit per annum annum out-of-hospital
benefit limit
Radial Keratotomy and 100% of the Scheme Rate funded from overall R15 000 per No benefit No benefit
Excimer laser treatment annual out-of-hospital benefit beneficiary
(performed in hospital per annum
or out-of-hospital setting)
Optical benefits (spectacles, 100% of the Scheme Rate funded from overall Annual limit per Annual limit per Overall annual
contact lenses, frames and annual out-of-hospital benefit family based on family based on out-of-hospital
all add-ons) Optometry Network applies: members will dependants: dependants: benefit limit
receive discounts as negotiated (discount M - R4 280 M - R2 145
applies to frames, eyeglass lenses and add-on M1+ - R8 560 M1+ - R4 290
components but excludes contact lenses and
professional services)
Eye tests 100% of the Scheme Rate funded from overall One test per One test per One test per
annual out-of-hospital benefit beneficiary per beneficiary per beneficiary per
annum annum annum
Allied professionals 100% of the Scheme Rate funded from overall R14 170 per family R9 835 per family Overall annual
(acousticians, biokineticists, annual out-of-hospital benefit, subject to the per annum per annum out-of-hospital
chiropractors, dietitians, Allied Professionals limit benefit limit
nursing providers,
occupational therapists,
physiotherapists,
podiatrists, psychologists,
psychometrics, social
workers, speech and
hearing therapists)
Mental health (psychologist 100% of the Scheme Rate funded from overall 15 consultations 15 consultations Overall annual
and counsellor) annual out-of-hospital benefit, subject to the per beneficiary per per beneficiary per out-of-hospital
Allied Professionals limit annum annum benefit limit
Drug and alcohol No benefit No benefit No benefit No benefit
rehabilitation, detox
and substance abuse
14PLAN A PLAN B PLAN C
Healthcare Service Basis of Cover Annual Limits Annual Limits Annual Limits
Acute medication (includes 100% of the Malcor Medication Rate funded from Annual limit per Annual limit per Overall annual
homeopathic medication, overall annual out-of-hospital benefit family based family based out-of-hospital
vaccines*, pharmacy DSP applies on number of on number of benefit limit
assisted treatment, TTO dependants: dependants:
obtained at a pharmacy *
Vaccines and immunisation to be funded based M - R11 235 M - R5 465
and over-the-counter on State EPI vaccines for infants and children up
medication) to the age of 12 years M1 - R16 055 M1 - R7 800
M2 - R20 865 M2 - R10 140
M3 - R27 300 M3 - R13 270
M4+ - R30 505 M4+ - R14 840
Over-the-counter sub limits M - R2 500 M - R1 500 No sub-limit. Subject
M2+ - R7 500 M2+ - R4 500 to overall annual
out-of-hospital
benefit limit
Chronic Illness Benefit Chronic Disease List
Maximum Medical Aid Price (MMAP) Funded from Funded from the Funded from the
Subject to medicine list (formulary). DSP applies the overall annual overall annual overall annual
in-hospital benefit in-hospital out-of-hospital
Subject to pre-authorisation and benefit entry benefit limit benefit limit
criteria
Additional Disease List
Maximum Medical Aid Price (MMAP) funded from Overall annual No benefit No benefit
overall annual out-of-hospital benefit out-of-hospital
DSP applies benefit limit
Subject to pre-authorisation and benefit
entry criteria
Contraceptives Oral contraceptives
100% of the Malcor Medication Rate funded from R130 per beneficiary R130 per beneficiary R130 per beneficiary
the overall annual out-of-hospital benefit, subject per month per month per month
to the acute medicine limit
DSP applies
Mirena device
100% of the Scheme Rate funded from the overall One every 5 years One every 5 years One every 5 years
annual out-of-hospital benefit
Subject to the acute medicine limit
DSP applies
Associated gynaecology costs for insertion and removal in the doctor’s rooms
100% of the Scheme Rate funded from Subject to the Subject to the Overall annual out-
the overall annual out-of-hospital benefit specialist annual specialist annual of-hospital benefit
limit per family limit per family
Associated gynaecology costs for Mirena insertion and removal in theatre
100% of the Scheme Rate Overall annual out- Overall annual out- Overall annual out-
Subject to pre-authorisation and benefit entry of-hospital benefit of-hospital benefit of-hospital benefit
criteria limit limit limit
Implanon nxt
100% of the Scheme Rate funded from One every 3 years One every 3 years One every 3 years
the overall annual out-of-hospital benefit
Subject to the acute medicine limit
DSP applies
Associated gynaecology cost for Implanon nxt implant or removal
100% of the Scheme Rate funded from Subject to the Subject to the Overall annual out-
the overall annual out-of-hospital benefit specialist annual specialist annual of-hospital benefit
Subject to the specialist annual limit per family limit per family limit per family
15PLAN A PLAN B PLAN C
Healthcare Service Basis of Cover Annual Limits Annual Limits Annual Limits
Musculo-skeletal topical 100% of the Malcor Medication Rate funded from 65mg per fill, 65mg per fill, 65mg per fill, limited
agents (Topical Analgesic overall annual out-of-hospital benefit, subject to limited to two fills limited to two fills to two fills per
Agents) the acute medicine limit per beneficiary per beneficiary annum
DSP applies per annum per annum
Screening Benefit 100% of the Scheme Rate funded from the overall Combined Combined benefit Combined benefit of
Dis-Chem WellScreen annual out-of-hospital benefit benefit of two of one screening one screening test
screening tests test per beneficiary per beneficiary per
per beneficiary per per annum** annum**
annum*
Screening Benefit 100% of the Scheme Rate funded from overall Combined Combined benefit Combined benefit of
annual out-of-hospital benefit benefit of two of one screening one screening test
screening tests test per beneficiary per beneficiary per
per beneficiary per per annum** annum**
annum*
Annual health check (blood Annual health check to be carried out at
glucose test, blood pressure the Wellness network pharmacy/provider
test, cholesterol test and
Body Mass Index (BMI))
Screening Benefit - 100% of the Scheme Rate funded from overall One test per One test per One test per
Children’s screening check. annual out-of-hospital benefit qualifying child per qualifying child per qualifying child per
Applies to children between Children’s screening tests to be carried out annum annum annum
the ages of two years and at a network pharmacy/provider
18 years (Body Mass Index
and counselling, where
appropriate, hearing
screening, dental screening
and milestone tracking for
children under the age
of eight)
* Member may claim for a maximum of two screening tests per annum and may choose to use either the Dis-Chem WellScreen test or the Health Check or both.
** Member may claim for a maximum of one screening test per annum and may choose to use either the Dis-Chem WellScreen test or the Health Check.
16The Malcor Medical Aid Scheme benefit tables
Hospital benefits: plan D
Benefit limits are prorated if a member joins the Malcor Medical Aid Scheme during the year unless otherwise
stated. Pre-authorisation required, except in the case of an emergency. In all instances, Prescribed Minimum
Benefits (PMBs) are paid at cost and are unlimited.
Service Benefits/annual limits Benefit requirements/conditions
Overall annual limit No annual limit Subject to protocols and sub-limits not being exceeded
Statutory Prescribed Minimum Benefit No annual limit
services rendered by public hospitals
payable at 100% of cost
Emergency medical cover while travelling 100% of SA tariff rates payable
outside of South Africa in RSA currency
BENEFIT REQUIREMENTS/
SERVICE BENEFITS ANNUAL LIMITS
CONDITIONS
1. HOSPITALISATION AND ASSOCIATED COSTS - PROVINCIAL AND PRIVATE
Items 1.01 – 1.21: All admissions to hospitals and services listed below must be pre-authorised by the Designated Service Provider.
Tel: 0860 00 24 02.
The Scheme will pay the costs of Prescribed Minimum Benefits in full for the involuntary use of a non-Designated Service Provider and 100% of
the Scheme Rate for services obtained from a Designated Service Provider.
Overall annual limit R600 000 per family per annum Subject to sub-limits not
being exceeded
1.01 Accommodation, theatre fees medicines, 100% of Managed Care Rate Subject to PMBs as prescribed Medicine dispensed
intensive care on discharge limited
to a five-day supply
1.02 Surgical procedures in hospital 100% of Managed Care Rate Subject to PMBs as prescribed
including GP and specialist consultations Hip Arthroscopy not covered Private wards not covered
1.03 Diagnostic investigations 100% of Managed Care Rate Authorisation must be Subject to clinical
e.g. Radiology, Pathology, MRI/CAT scans etc. obtained prior to the protocols and PMBs
examination or within as prescribed
24 hours in case of an MRI and CT Scans must
emergency be authorised by the
Limited to R8 000 per Scheme, or the Managed
family per annum Health Care Organisation
1.04 Blood transfusions 100% of cost
1.05 Oncology treatment 100% of Managed Care Rate Limit of R200 000 per family Subject to PMBs
Subject to ICON protocols per annum as prescribed
1.06 Accommodation for confinements 100% of Managed Care Rate NVD – Limited to three (3) Subject to PMBs
Note: Waiting period may be applied, subject days and two (2) nights as prescribed
to the rights of interchangeability Caesar – Limited to four (4)
days and three (3) nights
Limited to two sonars per
confinement
1.07 Psychiatric treatment and clinical No benefit Subject to PMBs as
psychology prescribed
Drug and alcohol
treatment at SANCA
affiliated facilities only
1.08 Organ transplants 100% of Managed Care Rate Limited to R86 400 per family Subject to PMBs as
per annum prescribed and pre-
Cornea transplants: only authorisation. Only locally
locally harvested corneas harvested corneas will be
will be covered covered
17BENEFIT REQUIREMENTS/
SERVICE BENEFITS ANNUAL LIMITS
CONDITIONS
1.09 Renal dialysis 100% of Managed Care Rate Limited to R1 047 per Subject to pre-
treatment authorisation from the
Scheme’s designated
Managed Health Care
Service Provider
1.10 Dental hospitalisation No benefit
1.11 Sterilisation / vasectomy No benefit (Revisions excluded)
1.12 Internal prosthesis 100% of cost Limited to R18 576 per case Subject to PMBs
per annum as prescribed and
Cardiac stents – one per pre-authorisation
lesion, maximum three Cardiac stents are
lesions reimbursed at the cost of
Aphakic Lenses – R3 715 bare metal stents (BMS)
per lens and not drug eluting
stents (DES). (Revisions
excluded)
1.13 Physiotherapy 100% of Managed Care Rate Subject to PMBs
as prescribed and
pre-authorisation
1.14 Step down facilities 100% of Managed Care Rate Limited to a maximum of two Subject to PMBs
Instead of hospitalisation weeks per person per annum as prescribed and
pre-authorisation
1.15 Private nursing 100% of Managed Care Rate Limited to a maximum of two Subject to PMBs
Instead of hospitalisation weeks per person per annum as prescribed and
pre-authorisation
1.16 Rehabilitation facilities 100% of Managed Care Rate Limited to a maximum of two Subject to PMBs
weeks per person per annum as prescribed and
pre-authorisation
1.17 Circumcision 100% of Managed Care Rate Limited to R1 048 per person
In- and out-of-hospital per annum
1.18 Hyperbaric Oxygen Therapy No benefit
1.19 Back surgery 100% of Managed Care Rate Subject to PMBs
as prescribed and
pre-authorisation
Subject to back treatment
protocols
1.20 Stereotactic Radiosurgery No benefit
1.21 Laparoscopic Procedures No benefit Subject to PMBs
as prescribed and
pre-authorisation
18Out-of-hospital benefits: Plan D
Benefit limits are prorated if a member joins the Malcor Medical Aid Scheme during the year unless otherwise
stated. In all instances, PMBs are paid at cost and are unlimited.
BENEFIT REQUIREMENTS/
SERVICE BENEFITS ANNUAL LIMITS
CONDITIONS
2. GENERAL PRACTITIONERS AND SPECIALISTS
2.01 Consultations
General Practitioners 100% of Managed Care Rate No annual limit Subject to member’s choice
of nominated GP
Specialists 100% of Managed Care Rate Limited to four visits per Subject to referral from
family per annum nominated GP
Outpatient facilities 100% of Managed Care Rate Two visits per family per
annum
2.02 Antenatal care 100% of Managed Care Rate Limited to two sonars Note: waiting periods may apply
Included in sub limits for consultations per pregnancy subject to the rights
and medication of interchangeability
2.03 Diagnostic investigations Subject to PMBs as prescribed
Pathology 100% of Managed Care Rate Limited to R800 per
person per annum
Radiology 100% of Managed Care Rate Limited to R800 per
person per annum
MRI/Cat Scans No benefits
3. MEDICINES
3.01 Acute medicines 100% of Designated Service Unlimited subject to
(including homeopathic medicine) Provider reference price medicine dispensed by
the nominated GP and
medicine formulary
3.02 PMB Chronic Disease List (CDL) 100% of Designated Service Unlimited, but subject PMBs subject to registration
medicines Provider reference price to Designated Service and pre-authorisation of the
Providers’ treatment medicine with the Scheme’s
protocols and medicine Preferred Provider,
formulary Tel: 0860 00 24 02
3.03 Other chronic (non-CDL) medicines 100% of Designated Service Unlimited, but subject Non-CDL PMBs subject
Provider reference price to Designated Services to registration and
Providers’ treatment pre-authorisation of the
protocols and medicine medicine with the Scheme’s
formulary Preferred Provider,
Tel: 0860 00 24 02
3.04 Pharmacy Advised Treatment (PAT) 100% of Managed Care Rate R300 per family per
Over the counter medication. annum at R100 per
In consultation with pharmacist, event
restricted to schedule 0, 1 and
2 medicines
4. OPTICAL BENEFITS
Contact the Designated Service Provider for availability of contracted optometrists Tel: 0860 002 402
4.01 Spectacle lenses 100% of cost Limited to R810 per Subject to using the Scheme’s
In Network Benefits person payable every Designated Service Provider
24 months
4.02 Spectacle lenses Included in limit 4.01 above
Out of Network Benefits
Applicable to members who choose to
utilise a non-Preferred Provider Network
Optometrists
4.03 Contact lenses No benefit
In and Out of Network
4.04 Frames Included in limit 4.01 above
In and Out of Network
4.05 Eye tests Included in limit 4.01 above
In and out of Network
19BENEFIT REQUIREMENTS/
SERVICE BENEFITS ANNUAL LIMITS
CONDITIONS
5. DENTISTRY
5.01 Conservative dentistry 100% of Managed Care Rate Subject to overall Pre-authorisation required from
(e.g. fillings, extractions and X-rays) annual limit Designated Service Provider
Tel: 0860 10 49 25
5.02 Specialised dentistry No benefit
(e.g. crowns, bridge-work, dentures,
orthodontics and periodontics)
5.03 Maxillo facial and oral surgery No benefit
(consultations, surgical procedures
and operations)
6. ALTERNATIVE SERVICES
6.01 Chiropractic, homeopathy, podiatry and No benefit
naturopathy
7. REMEDIAL AND OTHER THERAPIES
7.01 Audiology, dietitians, hearing aid No benefit
acousticians, occupational therapy,
orthoptics, social workers and
speech therapy
8. APPLIANCES
8.01 Appliances No benefit Subject to PMBs as prescribed
(e.g. hearing aids, wheelchairs,
calipers etc.)
9. EXTERNAL PROSTHESIS
9.01 External prosthesis No benefit Subject to overall Subject to PMBs as prescribed
(e.g. artificial limbs, eyes, etc.) annual limit Pre-authorisation required from
Designated Service Provider
Tel: 0860 10 49 25
10. PHYSIOTHERAPY (out of hospital)
10.01 Physiotherapy No benefit Subject to PMBs as prescribed
(out-of-hospital)
11. OTHER BENEFITS
11.01 Ambulance services 100% of cost Non-emergency: Subject
LifeMed 0861 086 911 to pre-authorisation
beforehand. Failure to
(air/road ambulance and do this could result in the
emergency services) member being liable for
the costs incurred
Emergency: Subject to
authorisation within 72 hours
after the emergency
Inter-hospital transfers: must be
done by the Designated Service
Provider only
11.02 HIV/AIDS and sexually 100% of Managed Care Rate Subject to Regulation 8(3)
transmitted diseases Subject to treatment protocols,
medicine formulary and
registration of chronic
medicine by the member’s
nominated GP
11.03 Infertility 100% of Cost Subject to PMBs as
prescribed
20Medicine benefits
GENERAL GUIDELINES: The Scheme applies the following guidelines in respect of medicine benefits on Plans A,
B and C:
Generic medication Medicine price structure
Generic medicines are produced once patents of original Current legislation regulates the pricing of all medication and
drugs have expired. They have the same active ingredients as the Scheme will cover medication up to a maximum of this
the original medicines. They may, however, be in a different Single Exit Price, subject to MMAP(R). Legislation also allows
form from the original drug and will not be in the same for a dispensing fee to be charged and this is covered by
packaging. the Scheme up to the amount charged by the Scheme’s DSP,
being Dis-Chem.
By using generics, members can use less of their Acute
Medicine Benefit each time they claim. However, members However, administrative costs, including those for faxes,
are still assured of quality because all generic medicines sold telephone calls, transaction and delivery fees and any other
in South Africa must be approved by the Medicines Control sundry fees charged by the medication supplier, are not
Council. covered by the Scheme.
Maximum medical aid price (MMAP(R)) Medication preferred provider
The Scheme covers the cost of medication up to the Dis-Chem have been appointed as the Scheme’s Designated
recommended MMAP(R). This price represents the lowest Service Provider (DSP) for all medication requirements.
average price available in the marketplace for a particular Dis-Chem have offered the Scheme a beneficial dispensing
classification of drug. This price is in most cases the lowest fee structure. Should a member choose to obtain their
average generic price as well. medication from a provider who is unable to match this
dispensing fee arrangement, they will be personally liable
Members are fully responsible for the difference between the
for any resultant excess.
actual price charged for medication and the related MMAP(R)
level. For this reason members are urged to ask their doctors
to prescribe generic medication wherever possible. Over-the-counter medicines (OTC)
If there is no generic alternative on the MMAP list, the full
cost of the original drug will be paid by the Scheme. Pharmacists can prescribe and dispense schedule 0, 1
and 2 medicines for the treatment of minor ailments
suchas dysmenorrhoea, headaches, sinusitis, abdominal
colic, stomach cramps, dyspepsia, heartburn, constipation,
diarrhoea, muscular pain, coughs and colds, flu, sprains,
insect bites, rashes, itchy skin, hayfever, nausea and
vomiting, migraines, worms, vaginitis, anti-fungal and anti-
viral conditions. These costs will be paid by the Scheme and
deducted off the relevant plan-specific acute medicine OTC
sub-limit.
Visit
www.malcormedicalaid.co.za > Medicine for more
information.
21Medicine Benefit
TYPE OF MEDICINE OBTAINED FROM PRESCRIBED BY PAID FROM
Medicines given to you while
you are in-hospital (you are In-Hospital Benefit
an admitted patient)
Medicines given to you when
you leave the hospital (you are being
IN-HOSPITAL
discharged as a patient).
Hospital Benefit
Medicine is billed by the hospital
directly – you are not handed a script
to collect from the pharmacy
Medicines given to you when
you leave the hospital (you are being
Seven day supply:
discharged as a patient).
paid from your Acute
Medicine is not billed by the hospital
Medicine Benefit
directly – you are handed a script
to collect from the pharmacy
Prescribed acute
or Acute Medicine Benefit
(schedule 0-6)
Approved prescribed chronic
(must be registered on the or Chronic Illness Benefit
OUT-OF-HOSPITAL
Chronic Illness Benefit)
Acute Medicine Benefit
Pharmacy prescribed or self-
(up to the over-the-
prescribed or
counter medicine
(schedule 0, 1 or 2)
sub-limit)
Acute Medicine Benefit
Approved vitamins or or Managed Care
(HIV, Oncology, Pre-natal only)
Programme risk
Prescribed vitamins
Iron, single and multivitamins with a
NAPPI code, only when prescribed by
a physician. Limited to R75 and/or Acute Medicine Benefit
500ml/60 tablets per script. Tonics,
mineral supplements and baby food
is not covered.
Hospital Pharmacy Doctor Self
22Prescribed Minimum
Benefits (PMBs) and
Designated Service
Providers (DSPs)
What is a PMB?
Prescribed Minimum Benefits are prescribed by law
as a minimum benefit package to which each medical
scheme member is entitled. The Council for Medical Scheme’s
regulations require that medical schemes need to provide
cover for certain conditions even when scheme exclusions
or waiting periods apply, or when the member has reached
the limit for a benefit.
How PMB claims are paid
Your cover depends on whether you choose to use the Malcor
Medical Aid Scheme’s Designated Service Providers (DSPs) or not.
The Malcor Medical Aid Scheme has selected MediClinic
facilities as the Scheme’s in-hospital Designated Service
Provider (DSP) or “network”. The latest list of hospitals and
other service providers is available at www.malcormedicalaid.
co.za > Doctor visits > Find a healthcare professional
What we cover as a prescribed
minimum benefit
The Prescribed Minimum Benefits make provision for the
cover of the diagnosis, treatment and ongoing care of:
• 270 diagnoses and their associated treatment
• 27 chronic conditions
• Emergency treatment.
REMEMBER
Your hospital admission is subject to approval and
pre-authorisation. If you need to be admitted for emergency
medical treatment, please arrange for authorisation 72 hours
after your admission or have a family member contact
us to arrange this.
Out-of-hospital PMB cover is subject to approval and
pre-authorisation. The application form can be downloaded
from www.malcormedicalaid.co.za > Find a document
or by calling the Scheme on 0860 100 698.
Benefit tip:
If you choose to use the Malcor Medical Aid Scheme’s DSPs, the Scheme will pay your medical expenses in full, from your
Hospital Benefit. If you choose not to use a DSP, the Scheme will pay for medical expenses incurred while you are admitted
to hospital at up to the Scheme Rate. You will be responsible for the balance as a co-payment.Cover for
emergencies
Your health benefits also include cover for medical emergencies in South Africa.
Emergencies in South Africa Motor vehicle accidents
In an emergency, call Discovery 911 on 0860 999 911 - The member must inform the Scheme about the accident
this number is displayed on your membership card as soon as possible. Discovery Health will assist with the
for easy reference. Road Accident Fund claim in the following ways:
•
Discovery Health will refer the member to a Discovery
Cover while travelling overseas Health approved attorney who will assist the member with
their claim against the Road Accident Fund (the member
If you require emergency medical services while overseas,
may however make use of their own attorney)
that would normally be covered by the Malcor Medical Aid
Scheme, you can claim the reimbursement of the cost •
If the member uses one of Discovery Health’s approved
of these services back from the Malcor Medical Aid Scheme attorneys, those attorneys will analyse the member’s
on your return. The Malcor Medical Aid Scheme will refund accident (at no cost to the member) to determine whether
you at the Malcor Rate that would have been paid if emergency the member has a valid claim
medical services had been obtained in South Africa.
•
If the member chooses to use their own attorney,
Please download the international claim form from the the member should ask their attorney to contact the
website and send it to us with the detailed claim so that we Scheme in order to assist the member’s attorneys with
can review the claims for payment. the accident-related accounts and any fee-related queries
which the attorneys may have.
In an emergency, please call the Discovery 911 The Scheme will pay for accident-related healthcare expenses
emergency services number which you will find on in accordance with the rules of the Scheme and the member’s
your membership card and the carsticker that has plan type.
been provided (Plan A, B and C only).
If the Road Accident Fund pays for medical expenses which were
also paid by the Scheme, the Scheme must be reimbursed in
accordance with the amount paid by the Road Accident Fund.
Malcor medical aid scheme emergency
service
Cover is provided for emergency medical evacuations.
The Discovery Medicopters, supported by ground staff,
provide medical support and air evacuation in extreme
critical cases. The emergency helicopters operate from
Johannesburg, Cape Town and Durban.
24Advanced technology
and convenience
When you’re at the doctor – health ID The data captured through this device integrates
seamlessly with HealthID (an application that doctors
HealthID, Discovery Health’s application for healthcare can download) to access members’ information remotely
professionals, is the first of its kind in South Africa. and identify risks in a timely manner.
Many doctors in the network will be able to access
These benefits allow doctors to spend less time downloading
your health records with your consent. Remember that
data and more time focusing on the health of patients,
member confidentiality will be protected at all times and
making diabetes management easier for members
your information can only be accessed with your consent.
of the Malcor Medical Aid Scheme. These benefits
are provided through Dis-Chem pharmacies and will
Managing diabetes digitally
be funded subject to your external medical appliances
The Malcor Medical Aid Scheme will fund a telemetric limit and overall out-of-hospital limit.
glucometer for all members registered for diabetes.
These devices provide an efficient and simple user Online bookings:
interface for capturing blood glucose readings
and insulin levels, and for logging exercise and You can conveniently use the Discovery app to
meals – all in real time. make real time online bookings. You can download
the Discovery app by going to the Apple AppStore
or Google Play.Reporting fraud or malpractice
Be part of the solution and not the problem. Report any Fraud hotline (anonymous)
fraudulent or unethical practice to us and take an active
role in combating crime. To report any crime related activity, call anonymously
on the toll-free number 0800 004 500 or SMS your report
to 43477. This is a totally independent, professional
hotline service.
Key information
The Scheme pays the applicable Malcor Rate directly to Important notes
providers as standard practice. If medical providers charge
in excess of Malcor Rates, the member will then have to settle 1. Healthcare practices must be appropriately registered
the balance with the relevant provider. with the Board of Healthcare Funders (BHF) and must
have a valid practice number in order for claims to
Should a member pay a provider directly and submit his claim
be considered.
with proof of receipt, the Scheme will refund the Malcor Rate
to the member. 2. The Scheme Rate is set by the Scheme for reimbursement
or it is the rate agreed between the Scheme and the
NB! All medical aid refunds are done electronically and members
provider. Discovery Health has been mandated to
are urged to ensure their banking details with the Scheme
negotiate certain rates on behalf of the Scheme.
are always updated.
How to claim
Important tips when claiming
When claiming from the Scheme for your medical costs,
EMAIL AND FAX
whether these are hospital, chronic or out-of-hospital, You can fax your claims to us on 0860 FAX CLAIMS
these steps apply: (0860 329 252), or scan and email your claim
to claims@malcormedicalaid.co.za
• When sending claims, please make sure the following
details are clear: POST
– Your membership number You can post your claims to the following address:
– The service date PO Box 1181
– Your doctor’s details and practice number Parklands
– The amount charged 2121
– The relevant consultation, procedure or NAPPI codes
and diagnostic (ICD-10) codes Claim drop-off boxes
– The name and birth date of the dependant for whom You can drop your claims in the Discovery Health claims
the service performed drop-off boxes situated around the country, in convenient
– If paid, attach your receipt or make sure the claim places such as pharmacies and medical practices, as well
says ‘paid’ as most Virgin Active or Planet Fitness gyms.
• Check with your healthcare providers if they have sent The Malcor Medical Aid Scheme claims boxes will remain
your claims to us to avoid duplicates in place at the various employer groups and you may continue
• Send your claims within four months of the date of service, to use these.
otherwise they will be treated as expired and will
not be paid Claim queries
• Always remember to keep copies of your claims For any claim queries, call the Scheme on 0860 100 698
for your records or email service@malcormedicalaid.co.za. Note this email
• To see the status of your claim, you can go to address should not be used to submit your claims.
www.malcormedicalaid.co.za
Changing plans
Members have freedom of choice between the four plans.
Members may change plans with effect from January each
year. Members may request a plan change at the end of
the year when the year-end communication is sent out
by the Scheme.
26You can also read
