Netcare Medical Scheme Member Brochure 2018 - Medical Billing ...
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Netcare Medical Scheme
Member Brochure 2018
CARE | DIGNITY | PARTICIPATION | TRUTH | PASSION
This Member Brochure is intended to summarise the Rules of Netcare Medical Scheme applicable to the principal member and his or her dependants registered with the Scheme. A copy of the full set of Rules can be obtained from the Scheme’s website at www.netcaremedicalscheme.co.za. Should a discrepancy arise between this Member Brochure and the rules of the Scheme, the rules of the Scheme will take precedence. 2018
TABLE OF CONTENTS
Introduction ............................................................. 3 In-theatre dentistry .................................................................... 14
Scheme overview......................................................................... 3 Dentistry .................................................................................... 14
Golden rules................................................................................. 3 The payment of unauthorised services ..................................... 15
Cover for chronic conditions ...................................................... 15
Membership ............................................................ 4
How to avoid out-of-pocket expenses ....................................... 17
Eligibility ...................................................................................... 4
Preventative healthcare ............................................................. 17
Retention of membership............................................................. 4
Benefit summary ....................................................................... 18
Application for membership ......................................................... 5
Supporting documentation .......................................................... 6 Special features .................................................... 21
Waiting periods ............................................................................ 7 Compassionate Care Benefit (CCB) ......................................... 21
Membership cards ....................................................................... 7 Oncology – Advanced Illness Benefit ....................................... 21
Change of personal details .......................................................... 8 Maternity Care Benefit ............................................................... 21
Monthly contributions .................................................................. 9 Substance abuse focus ............................................................. 21
Late joiner penalties..................................................................... 9 HIV/AIDS wellness programme ................................................. 21
Termination of a dependant or membership................................. 9 Emergency medical evacuations ............................................... 21
International travel cover ........................................................... 21
Structure of benefits.............................................. 10
Self service facilities .................................................................. 22
Expenses payable from the Scheme’s
DiabetesCare programme (DCB) .............................................. 22
insured/risk portion .................................................................... 10
Expenses payable from your Member Administrative requirements ................................. 22
Savings Account (MSA) ............................................................. 11
Claims administration ................................................................ 22
Important information you should know Membership statements ............................................................ 23
before utilising your benefits ................................. 12 Member Savings Account (MSA) .............................................. 23
Scheme appointed Designated Service Providers (DSPs) ....... 12
Exclusions............................................................. 24
Preferred Provider arrangements .............................................. 12
Important terminology ........................................... 26
Benefits requiring pre-authorisation .......................................... 12
Ex Gratia Policy .................................................... 28
Benefits with limits...................................................................... 13
Complaints and appeals process.......................... 28
Benefits ................................................................ 14
Pocket Guide ........................................................ 29
Hospital admission and treatment whilst in hospital .................. 14
Contact details ...................................................... 30
Authorisation ............................................................................. 14
INTRODUCTION
Netcare Medical Scheme is pleased The Board of Trustees is responsible
to present you with your Membership for the setting of the rules that govern If possible, negotiate rates
Brochure and quick reference Pocket the Scheme, for determining the with service providers
Guide. The Scheme trusts that you benefits available to members and the to mitigate or reduce
will find these documents informative contributions charged,whilst ensuring payments due by yourself.
and helpful over the coming year, the financial stability of the Scheme
Make sure to access the
during which the Scheme remains as and equitable access to benefits for
wellness benefits offered by
committed as ever to meeting your all members.
the Scheme.
healthcare needs and those of your
loved ones. If you have any chronic
conditions, enquire about
Please take time to familiarise yourself Golden Rules the Scheme’s specific
with the contents of the Brochure and
treatment plans.
the summary of your benefits in the Familiarise yourself with the
Pocket Guide so that you are fully rules of the Scheme. Check your claims
informed about your membership and notification or member
Understand your rights
the benefits available to you. Should statement and review the
and responsibilities as
you have any enquiries whatsoever claim details and available
a member.
regarding your membership and/or benefit limits. You can also
benefits, please do not hesitate to Obtain pre-authorisation review claims information
contact the Client Contact Centre on where necessary – even for and benefits on the
0861 638 633. follow-up visits. Scheme’s website
www.netcaremedicalscheme.
Remember authorisation
co.za.
Scheme Overview does not guarantee full
settlement of a claim. Finally, if in doubt about
The Netcare Medical Scheme was anything, email or phone
Always make use of
established in 1999 to provide excellent the Client Contact Centre.
the Designated Service
healthcare benefits that would truly make
Providers or Preferred
a difference in the lives of Netcare
Providers available to you.
employees and their families.
The Netcare Medical Scheme is
managed by a Board of twelve Trustees.
3
MEMBERSHIP
ho is eligible for membership to
W etention of membership in the event
R
the Netcare Medical Scheme? of retirement, ill-health or death
The Netcare Medical Scheme is a closed medical scheme
Members may retain their membership of the Scheme
and membership is restricted to permanent employees, in the event of retirement or when their employment is
pensioners and disability claimants of Netcare Limited. terminated by Netcare Limited or a subsidiary of the Group
on account of ill-health or other disability.
At the time of their application or at any time thereafter,
employees who join the Scheme may apply to have
Registered dependants may continue membership in the
children and/or adults added to their membership unfortunate event of the death of the main member as long
as dependants. Dependants have to qualify for as they continue to pay all contributions that become due.
Scheme membership.
ho is not eligible for membership
W
to the Netcare Medical Scheme?
Members of the Scheme who resign from the employment
of Netcare Limited or a subsidiary of the Group, together
with their dependants, lose their membership to the Scheme.
Employees who were not members of the Scheme before
retirement or the termination of their services on account
of ill-health or other disability are not eligible to become
members of the Scheme.
The dependants of a deceased member who initially
retain membership after the death of the main member,
but who later resign from the Scheme for any reason
whatsoever, are not allowed to re-join as members once
they have resigned.
Those dependants of deceased members, or members who
are retirees or who suffer from ill-health and disability, lose
their membership to the Scheme if the Scheme terminates
their membership as a result of non-payment of contributions.
4
How to apply for membership
Obtain
An application form can be Complete Submit
obtained from: Complete your application and Submit the completed application
1. Your HR Department; or attach the required supporting and supporting documentation
2. The Scheme’s website documentation to your HR Department
www.netcaremedicalscheme.co.za
Incomplete and outstanding supporting documentation
Please note that incomplete applications and/or those
submitted without the supporting documentation All new applicants who are joining after 30 days from
as requested on the application form will not be date of employment are required to complete the medical
processed. If you have not received your Welcome questionnaire. Applicants must disclose to the Medical
Pack and membership card within 21 days of Scheme information regarding any medical condition for
submitting your application please call our Client which medical advice, diagnosis, care or treatment was
Contact Centre on 0861 638 633 to enquire about the recommended or received over the twelve (12) months
status of your application. prior to their date of application. This requirement applies
to the applicant and his/her dependants and includes but
is not limited to medical conditions and/or diseases that:
Application forms must be stamped and submitted via
your Human Resources (HR) Department. No direct A member or and treatment that
submissions to the Scheme can be accepted. dependant suffers was recommended,
from as at the date but not necessarily
of application; taken;
No underwriting and waiting periods apply to A member or A member or
employees and their dependants who join the Scheme dependant was dependant obtained
within the first thirty (30) days of employment. diagnosed with medical advice
sometime over the not from a doctor
The Scheme may terminate membership if the member does past twelve (12) but from another
not disclose any and all relevant medical information. months, including healthcare provider
conditions that such as a pharmacist;
were diagnosed
The member or
but managed with
dependant had
lifestyle changes e.g.
any symptoms of
high cholesterol;
illnesses that were
A member or not specifically
dependant was diagnosed by a
treated for over the doctor, or for which
previous twelve (12) no specific treatment
months including was provided.
treatment received
6
Waiting periods
Where an employee joins the Scheme thirty (30) days after commencing employment, the Scheme may impose the following waiting
periods as provided for in terms of the Medical Schemes Act (No. 131 of 1998):
Application to
Three (3) month general 12 month condition-
Category Prescribed Minimum
waiting period specific waiting period
Benefits (PMBs)
New applicants, or persons who have not been Yes Yes Yes
a member of a medical scheme for the preceding
90 days
Applicants who were members of another medical No Yes No
scheme for less than two years
Applicants who were members of another medical Yes No No
scheme for more than two years and who did not
join within 30 days of employment
Child-dependants born during a period of No No No
membership and registered within 30 days of birth/
adoption
Addition of a spouse/life-partner within 30 days No No No
of marriage/proof of common household
Membership cards
The Scheme provides members with a Welcome Pack, which Welcome Packs and membership card(s) are
includes a membership card for the main member and all of the couriered to the relevant Human Resources
adult dependants on his/her membership. (HR) Departments. It is therefore essential
that the correct workplace or work site is
Membership cards may only be used by the registered member
clearly indicated on all application forms, and
and registered dependants. It is fraudulent to permit someone
else to use your medical scheme card and benefits. that notification is submitted of any transfers
to different sites.
7
Change of personal details
Change of to
Permission personal details details
change banking
In order for the Scheme to communicate with you effectively it is
important for you to notify us of changes to your contact details.
Contact details
Fax: 011 539
Tel: 0861 6387227
633 • PO Box PO Box 652509, Benmore, 2010 • www.netcaremedicalscheme.co.za
HR departments do not inform the Scheme of any Who we are
changes made to personal details. Therefore any
The Netcare Medical Scheme (referred to as ‘the Scheme’), registration number 1584. This is a non-profit organisation, registered with the
Council for Medical Schemes.
Discovery Health (Pty) Ltd (referred to as ‘the administrator’) is a separate company and an authorised financial services provider (registration
changes to personal details should be separately number 1997/013480/07). We take care of the administration of your membership for the Scheme.
What you must do
directed to the Scheme. Step 1: Fill in the form.
Step 2: Sign the application form.
Step 3: You need to submit the following with this form:
– Copy of the main member’s ID
– Bank statement/letter of confirmation from the bank not older than 3 months. (Please note: only an original bank statement will be
accepted).
When you sign this application, you confirm that the information provided is true and correct.
Alternatively, you can update your bank details by visiting www.netcaremedicalscheme.co.za if you are a registered web-user.
How to complete this form
• Please use one letter for each block, complete with black ink and print clearly.
• To avoid administration delays, please make sure this form is completed in full.
• Once it is complete, please fax the form to 0866 466 472 or email it to member@netcaremedicalscheme.co.za
1. What would you like to change?
Debit order details Claim payment details Both
2. Main member details
Membership number
ID number
3. New account details for debit orders
Update your information – When should we start using the new banking details 2 0 Y Y M M D D
it is as easy as 1…2…3… Please note that we cannot accept credit card details. You can only use a South African bank account.
Accountholder
Step 1 – To update your personal information, log on to the
Bank
Account number
Email: member@netcaremedicalscheme.co.za
Scheme’s website www.netcaremedicalscheme.co.za and go Type of account
Fax: 011
— 539
Cheque
— 7227
—
Savings
Branch name
Branch number
to the ‘YOUR DETAILS’ section. You can also obtain the
Registered post:
4. New account details for claims payments
Change of personal details form from the Scheme’s website
The Netcare Medical Scheme
When should we start using the new banking details? 2 0 Y Y M M D D
under the tab ‘Find a document’, or phone our Client Contact As per debit order details
Membership Department
Please note that we cannot accept credit card details.
Centre at 0861 638 633 for assistance. You may also request Accountholder
Bank PO Box 652509
a copy from your Human Resources (HR) Department. _ _ _
Benmore 2010
Account number Branch number
Type of account Cheque Savings
Step 2 – Complete the form and ensure it is signed and that Branch name
The Scheme shall not be liable if a member’s rights are
a copy of your Identity Document (ID) is attached. Netcare Medical Scheme, Registration number 1584, is administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised financial services provider. Page 1 of 2
prejudiced or forfeited as a result of neglect to comply with
Step 3 – Your completed form may be returned to the Scheme these requirements.
in one of the following ways:
8Monthly contributions including children from the age of Late joiner penalties
twenty-one (21) years. Additional
Membership contributions are deducted adult dependants must be financially Late joiner contribution penalties in
by the employer from the employee’s dependent on the member and respect of persons over the age of 35
monthly remuneration. This is paid to evidence to this effect is required years will be imposed as per the Medical
the Scheme every month in arrears on for acceptance on to the Scheme; Schemes Act and the membership rules
behalf of the member. Spouses, life-partners and any noted in this guide.
immediate family for whom the
Pensioners, dependants of deceased
members and disability claimants must
principal member is financially
responsible may apply to become a
Termination of a
make payment directly to the Scheme
dependant including children from the dependant
and may be liable for the full contribution
if they do not qualify for the Netcare
age of twenty-one (21) years.
or membership
post-retirement employer subsidy.
The number of child dependants.
The employer subsidy is determined You may terminate the membership of
All dependants younger than twenty-
by Netcare Limited. any of your dependants by notifying your
one (21) years are considered to
Human Resources (HR) Department
be child dependants. Children from
Late payments can result in suspended using the documentation provided by
the age of twenty-one (21) years,
benefits or cancellation of membership. the Scheme, giving one (1) calendar
registered as bona fide students
month’s written notice to the Scheme.
The Scheme calculates your contribution at an educational institution up to
using the Contribution Table (refer to the age of twenty five (25) years, Principal members may only terminate
the Pocket Guide for the Contribution subject to providing proof of current membership if they resign from
Table applicable to the particular year) registration at a tertiary institution employment with Netcare Limited or
based on: to the Scheme annually, are also provide proof of alternative medical
The income (rate-of-pay/ROP) of the considered to be child dependants. scheme cover (as a dependant).
principal member One (1) calendar month’s notice is
required using the necessary Scheme
The number of adult dependants
documentation.
defined as spouses, life-partners
and any immediate family for whom
the principal member is liable
9STRUCTURE OF BENEFITS
The benefit structure of the Netcare Medical Scheme includes a 15% Member Savings Account (MSA) component for day-to-day
expenses. Preventative benefits and high cost items are paid by the Scheme from the insured or risk portion.
Expenses payable from the Scheme’s insured or risk portion
The Scheme will cover expenses such as those noted below
Managed Care Protocols and Clinical Guidelines generally
from the insured or risk portion of benefits. Note that payment accepted in the industry as best practice principles
may be subject to: Co-payments
Pre-authorisation Sub-limits.
The following are covered from the insured or risk portion of your benefits:
Hospitalisation (including ward fees, theatre fees, ward
Unlimited specialised radiology such as CT, PET and MRI
medicine and treatment, surgery and anaesthesia etc.) scans and radio isotope studies
A seven (7) day supply of medication on discharge from Basic radiology
hospital (To-take-out/‘TTO’)
Maternity benefits (including home delivery), subject
General Practitioners, specialist and technician to registration on the Maternity Care Programme
consultations and treatment while in hospital
PMB Chronic Disease List chronic medication, subject
Physiotherapy and occupational therapy while in hospital to registration on the Chronic Illness Benefit
Organ transplants including donor costs, surgery and Prostheses
immuno-suppressant drugs Hearing aids (including repairs)
Unlimited chemotherapy, radiation and dialysis treatment
Appliances i.e. nebulisers, glucometers and blood
Injuries sustained in motor vehicle accidents subject pressure monitors with motivation
to an undertaking in favour of the Scheme
Ambulance and emergency services through Netcare 911
Routine diagnostic endoscopic procedures
Home-nursing, step-down facilities, physical rehabilitation
Outpatient or emergency department visits with a final and hospice services as an alternative to hospitalisation
diagnosis of a PMB or Priority Emergency or leading immediately following an event (excluding day-to-day care)
to an immediate admission HIV management
Specialist consultations out-of-hospital (full cover for Infertility interventions and investigations in line with PMBs
Preferred Provider specialists)
Conservative and specialised dentistry including
Pathology (using a Preferred Provider will ensure orthodontics
full cover)
Maxillo-facial and oral surgery
Prescribed Minimum Benefits in and out of hospital
Some preventative care benefits.
In-hospital dentistry – theatre and anesthetist accounts for
children under the age of 8 yearsExpenses payable from your Member
Savings Account (MSA)
The following day-to-day expenses are covered from your MSA:
General Practitioner services out-of-hospital
Non-emergency consultations at any Netcare emergency
department
All optical services (note: one optometric consultation per
beneficiary per annum is payable from the insured risk
portion of your benefits and is deducted from your specialist
consultation limit)
Prescribed acute medication
Self-medication or over-the-counter (OTC) medication
Vitamins
Homeopathic formulations
Physiotherapy and bio-kinetics out-of-hospital
Psychology and social services.
Treatment for the services above will be paid from your MSA only
if there is an available balance.
11Important things you should know before utilising your benefits
Network arrangements
Pre-authorisation is required to access the
The Scheme has Designated Service Provider (DSP) and
Preferred Provider arrangements in place. You should make sure
following benefits
that you use these appointed DSPs and Preferred Providers in Hospital admissions/home nursing/step
order to minimise your co-payments in- and out-of-hospital and/ down/sub-acute/rehabilitation and hospice
or to prevent claims from being rejected. Visit the Scheme’s Specialist visits (including follow up visits)
website at www.netcaremedicalscheme.co.za and log on to the out-of-hospital
MaPS tool through the ‘Doctor visits’ tab, for a complete list. Some radiology scans: IVP tomography,
contrast studies, bone densitometry, MRI,
Scheme appointed DSPs PET and CT scans
and mammograms
For all Hospital admissions:
– Any Netcare Hospital All appliances and prosthesis
Orthodontic treatment
Chronic medication – register first:
– Any Netcare Retail Pharmacy or pharmacies located All chronic medication
inside a Medicross facility (Pharmacross) Outpatient procedures
For Ambulance services: Obtain pre-authorisation at least 72 hours
prior to a planned event and within 72 hours
– Netcare 911
after an emergency.
Note
Exceptions are only allowed in an emergency as defined
in the Medical Schemes Act, No. 131 of 1998
A 25% co-payment for voluntary, non-emergency use
of any other service provider will apply.
Preferred Provider arrangements
Specialist Network
Pathology laboratories: Ampath, Lancet and Pathcare
National Renal Care Facilities
Netcare Oncology Units
Most Medicross Dentists
Medicross and Netcare Day Theatres
Storks Nest facilities
12Some benefits have limits
Annual limits applicable per beneficiary
Out-of-hospital pathology including consumables and materials Refer to the included Pocket Guide for the limit amount
per beneficiary
Psychiatric hospitalisation 21 days per beneficiary
Specialist consultations Nine (9) visits per beneficiary
Alcohol and drug rehabilitation 21 days per beneficiary
External and Internal prostheses Refer to the included Pocket Guide for the limit amount per
Hearing aids and hearing aid repairs beneficiary
Other appliances
Annual Family limits
*
Dentistry (overall limit applicable to basic and specialised, in-and Refer to the included Pocket Guide for the limit amount per family
out-of-hospital)
*
Includes orthodontic (braces) treatment
Basic Radiology (black and white X-rays and ultrasonography
Maternity limits (subject to registration on the Maternity Programme)
Ultrasound scans Two (2) ultrasound scans per pregnancy
Antenatal consultations at a Gynaecologist, 13 consultations per pregnancy
General Practitioner or Midwife units
Antenatal classes R1 000 per pregnancy at a Storks Nest facility
13BENEFITS
The benefit table shows the expenses that are
covered by the Scheme and limits, co-payments,
authorisation requirements and DSP or Preferred
Provider arrangements that may apply. Please refer
to the Pocket Guide that is included herewith for the
actual values of limits applicable in the particular
year; we would however like to highlight the following
additional important information below.
Hospital admission and treatment whilst
in hospital
A copy of the authorisation, including possible
exclusions, will be emailed to you (if details are
available), your treating doctor and the hospital.
Make sure to clarify any uncertainty you may have
with your treating practitioner or the Scheme prior
to your admission as some procedures, items and
medication may not be covered. Should the treating
practitioner disregard the terms and conditions of
the authorisation you will remain responsible.
Members are advised to, where possible, make use of
specialists and other medical service providers on the
Preferred Provider lists to optimise benefits and minimise
co-payments for treatment while in hospital. Please visit
the Scheme’s website at www.netcaremedicalscheme.co.za
for a list of DSPs and Preferred Providers of the Scheme.
Accommodation in a private ward is subject to a motivation
from the attending practitioner.
CT, MRI and PET scans in-hospital require a separate
authorisation but have no co-payment.
14Authorisation – a clinical confirmation, The payment of unauthorised services
not a guarantee of payment If you fail to obtain authorisation as required in terms of the
rules of the Scheme, the Scheme may:
Pre-authorisation is provided based on a clinical
decision and enables the Scheme to ensure that
Pay for the service from your available MSA in the
the treatment that is provided to you is clinically
appropriate and cost-effective. It should be noted event of a non-PMB diagnosis or alternatively reject
the account if you do not have savings available; or
that pre-authorisation is not a guarantee of payment.
Failing to obtain an authorisation may, in terms of the Apply a penalty equal to the difference between
rules of the Scheme, lead to claims not being paid or 100% of the NMS tariff and the cost charged
substantial co-payments even if the medical condition by the service provider for PMB diagnoses.
is a PMB.
Cover for chronic conditions
In-theatre dentistry
The Scheme covers approved chronic medicine for the
It is important to note that in-theatre dentistry is not paid 26 Prescribed Minimum Benefit (PMB) Chronic Disease List
from the unlimited hospital benefit but from the annual family (CDL) conditions.
dentistry limit. The complete treatment event including all
We will pay your approved chronic medicine in full up to
related accounts (e.g. dentist, surgeon, anaesthetist, theatre
the Scheme Rate if it is on the Netcare medicine list (formulary).
etc.) is paid from this limit with the exception of theatre and
anaesthetist accounts for children under the age of 8 years If your approved chronic medicine is not on the medicine list,
which will be paid from the unlimited hospital benefit. we will pay your chronic medicine up to the Maximum Medical
Aid Price (MMAP).
When a maxillo-facial surgeon performs a standard dental
procedure in theatre, the event is still payable from your The Scheme also covers approved medicine for the non
annual family dentistry limit. Only when a maxillo-facial Chronic Disease List condition, Depression. There is no
surgeon performs surgery pertaining to the jaw and face that medicine list (formulary) for this condition. We pay approved
is specialised and pre-authorised, will services be paid from medicines for this condition up to the Maximum Medical Aid
the unlimited risk portion of the Scheme’s benefits. Price (MMAP).
You must apply for cover by completing a Chronic Illness
Dentistry Benefit application form with your doctor and submitting
it for review. For a condition to be covered form the Chronic
It is important to note that all dental work in- and out-
Illness Benefit, there are certain benefit entry criteria that
of-hospital, as well as orthodontic work, forms part of
need to be met.
the dental benefit and is covered by the annual family
dentistry limit except for theatre and anaesthetist costs There is a DSP arrangement with Netcare Retail pharmacies
for children under the age of 8 years which will be paid and pharmacies located in Medicross facilities.
from the unlimited hospital benefit. Refer to the Pocket
Guide for details.
15Use of a non-DSP pharmacy will require upfront payment
The Scheme covers the chronic conditions detailed in the
from the member and the claim needs to be submitted to table below:
the Scheme in order for the member to be reimbursed. The
Addison’s disease
Scheme will refund the member at the fee that would have
Bronchiectasis
been payable if the medication was obtained from a DSP.
In other words, you may be liable for a co-payment if you Chronic obstructive pulmonary disease
do not use a DSP; Crohn’s disease
If your Chronic Disease List (CDL) condition is approved by Dysrhythmia
the Chronic Illness Benefit, the Chronic Illness Benefit will Haemophilia
cover certain procedures, tests and consultations for the Hypothyroidism
diagnosis and ongoing management of the condition in Parkinson’s disease
line with Prescribed Minimum Benefits.
Systemic lupus erythematosus
Out-of-pocket expenses can be avoided by using alternative Asthma
products that are less expensive. Discuss your options with your Cardiac failure
treating provider or pharmacist.
Chronic renal failure
Diabetes insipidus
Epilepsy
Hyperlipidaemia
Hypertension
Rheumatoid arthritis
Ulcerative colitis
Bipolar mood disorder
Cardiomyopathy
Coronary artery disease
Diabetes mellitus type 1 and 2
Glaucoma
Depression
Multiple sclerosis
Schizophrenia
16How to avoid out-of- Obtain a pre-authorisation for any
Baby and child immunisations
specialist follow-up consultations
pocket expenses that may be related to your hospital
Standard immunisations up to
the age of twelve (12) years in
Confirm that we have your latest
admission, as follow-up consultations
accordance with the Department
email and cell phone details as do not form part of the hospital
of Health protocols (excluding the
authorisation confirmation will be authorisation process.
HPV vaccine).
sent to you on the contact details that Few anaesthetists charge scheme
we have on system in the event of a rates. It is therefore a good idea MMR vaccine for measles, mumps,
hospital admission. to ask your doctor/surgeon which and rubella (also called German
anaesthetist he/she makes use measles).
Read the authorisation letter/
SMS and familiarise yourself with of and negotiate fees with Health tests*
the terms and conditions i.e. scheme them upfront.
Blood sugar test
exclusions and limits associated
with the procedure. If you have any Preventative healthcare Cholesterol test
questions or are not sure about HIV test
anything please speak to your Preventative care is an important part of
Pap smear
treating healthcare practitioner and/ maintaining good health. We encourage
our members to make use of this special Prostate test.
or one of our Case Managers before
you are admitted to hospital. benefit as it can assist you in ensuring
Scans*
that you maintain your good health.
Make use of a Netcare hospital.
These benefits are paid from the insured Bone densitometry scan (males and
If you choose to use any other
risk portion subject to the terms and females 50 years and older).
hospital in a non-emergency
conditions of the rules of the Scheme. Mammogram.
situation, it will result in a 25% co-
Refer to the included Pocket Guide for
payment on the Hospital account
more detail. For the expecting mother
associated with the event.
Make use of a Preferred Provider Thirteen (13) antenatal consultations
(a contracted doctor/surgeon) as the
The Scheme provides at a Gynaecologist or General
Scheme has negotiated fees with cover for the following: Practitioner.
them and they are not allowed to Two (2) ultrasound scans per
charge more than has been agreed
Flu immunisations* pregnancy.
with them by the Scheme. If they do Flu vaccination – one (1) per
charge more than the agreed upon beneficiary per year (specific vaccine * One (1) per beneficiary per annum
rate please notify us without delay so as determined by the Scheme at a at 100% of the NMS tariff. Refer to
that we can assist you in resolving DSP pharmacy only). the Pocket Guide for the complete list
the matter. of codes funded.
17NETCARE MEDICAL SCHEME BENEFIT SUMMARY
In-hospital cover
A list of the Designated Service Providers (DSPs) and Preferred Providers is available at www.netcaremedicalscheme.co.za or by calling the Client Contact Centre on 0861 638 633
Service Benefit Limits (Subject to managed care Authorisation Requirements Designated service
rules and protocols) provider (DSP)/
Preferred provider
Admission to Netcare hospital (DSP) – Failure to make use of a DSP or failure to pre-authorise any hospital admission will result in a 25% co-payment (including PMBs)
Hospital stay 100% of NMS tariff Unlimited cover Yes, at least 72 hours prior to admission or within At DSP
Psychiatric hospitalisation 100% of NMS tariff 21 days per beneficiary per annum or 15 72 hours of an emergency admission At DSP
outpatient psychotherapy sessions
Day clinic or day theatre admission 100% of NMS tariff Unlimited cover At DSP
To Take Out (TTO) drugs 100% of NMS tariff Seven (7) day supply Forms part of the related hospitalisation At DSP
No levy applicable
Treatment whilst in hospital
Consultations, surgical procedures, physiotherapy, 100% of NMS tariff Unlimited cover Forms part of the related hospitalisation At DSP
medication and blood transfusions
Anaesthetics 100% of NMS tariff Unlimited cover
Pathology 100% of NMS tariff Unlimited cover
Organ transplants (including donor cost and 100% of NMS tariff Unlimited cover Yes, at least 72 hours prior to admission or within At DSP
immunosuppressant medication) 72 hours of an emergency admission
Peritoneal dialysis and haemodialysis (kidney 100% of NMS tariff Unlimited cover Yes, registration on the renal treatment plan At DSP
dialysis) including renal unit and technicians required
Dentistry hospitilisation for children under the age 100% of NMS tariff Unlimited cover for theatre and anesthetist Yes, at least 72 hours prior to admission or within Preferred Provider
of 8 years 72 hours of an emergency admission use recommended to
Combined in- and out-of-hospital dentistry minimize co-payments
limit applies for dentist/dental surgeon
Refer to the included Pocket Guide for the
limit amount per family
Dentistry hospitilisation 8 years and older – 100% of NMS tariff Combined in- and out-of-hospital dentistry Yes, at least 72 hours prior to admission or within Preferred Provider
hospitilisation and all related accounts for dental limit applies 72 hours of an emergency admission use recommended to
treatment including theatre and anaesthetics Refer to the included Pocket Guide for the minimize co-payments
limit amount per family
Dentistry: maxillo-facial surgery 100% of NMS tariff Strictly related to certain treatment Yes, at least 72 hours prior to admission or within Preferred Provider use
72 hours of an emergency admission recommended to avoid
co-payments
Admission to a NON-DSP hospital (a non-DSP is defined as a provincial or private hospital other than a Netcare Hospital)
Hospital (voluntary admission) stay and all related 75% of NMS tariff 25% co-payment will apply Yes, at least 72 hours prior to admission or within –
services including consultations, surgical procedures, on hospital account 72 hours of an emergency admission
treatment, medication, physiotherapy, anaesthetics, etc.
Hospital (emergency/involuntary non-DSP 100% of NMS tariff Unlimited cover Yes, at least 72 hours prior to admission or within –
admission) will qualify for the same benefits as for a 72 hours of an emergency admission
DSP hospital admission
#emergency as defined in The Medical Schemes Act, No. 131 of 1998
Motor vehicle accidents and third party claims
Payment is subject to an undertaking and completion 100% of NMS tariff Unlimited cover Yes, at least 72 hours prior to admission or within At DSP
of an accident injury form and report by the member 72 hours of an emergency admission
Out-of-hospital cover
Chronic medication
Chronic medication benefit is applicable to members 100% of NMS tariff Unlimited cover (subject to MMAP, chronic Yes, once diagnosed At DSP (failure to utilise
and/or dependants registered on the Chronic Illness medicine list and PMBs). A limit applies the services of a DSP
Benefit for non CDL chronic medication will require upfront
(i.e. for depression) payment by the member
Refer to the included Pocket Guide for the and the submission of a
limit amount per beneficiary claim to the Scheme for
reimbursement)
Outpatient procedures and emergency visits
Gastroscopies and colonoscopies 100% of NMS tariff Unlimited cover at DSP Yes, at least 72 hours prior to procedure At DSP
R500 co-payment at non-DSPService Benefit Limits (Subject to managed care Authorisation Requirements Designated service
rules and protocols) provider (DSP)/
Preferred provider
Sigmoidoscopy, direct laryngoscopy, biopsy of breast 100% of NMS tariff Unlimited cover Yes, at least 72 hours prior to procedure At DSP
lumps, excision of nail bed, surgical removal of
plantar warts, non-cosmetic varicose vein injections
or drainage and wound care
Removal of wisdom or impacted teeth, removal of 100% of NMS tariff Combined in- and out-of-hospital dentistry Yes, at least 72 hours prior to procedure At DSP
retained dental roots in lieu of hospitalisation limit
Refer to the included Pocket Guide for the
limit amount per family
Outpatient or casualty procedure that results from a 100% of NMS tariff Unlimited cover Yes, at least 72 hours prior to procedure At DSP
procedure previously requiring hospital admission or within 72 hours of an emergency admission
(within 72 hours post-event)
Outpatient or casualty consultations, procedures, 100% of NMS tariff Unlimited cover None At DSP
medication and treatment defined as an #emergency
or a priority emergency
Specialist consultations and treatment out-of-hospital – failure to pre-authorise will result in payment being made from savings for non-pmb conditions or a co-payment on pmb conditions
Consultations, procedures in room, material and NMS negotiated Nine (9) consultations per beneficiary per Yes, at least 72 hours prior to consultation Preferred Provider use
visits (including outpatient visits) tariff at contracted annum or procedure or within 72 hours of an emergency recommended to avoid
Preferred Provider co-payments
100% of NMS tariff Use of a non-Preferred
at non-contracted Provider may lead to
provider co-payments
One specialist consultation per beneficiary per annum may be utilised for an optometric consultation None –
Oncology
Any oncology treatment including chemotherapy and 100% of NMS tariff Unlimited cover Yes, registration on oncology programme required At DSP
radiation in - and out-of-hospital at DSP and submission of a treatment plan
Pathology
Pathology including consumables and materials 100% of NMS tariff Refer to the included Pocket Guide for the None Preferred Provider use
limit amount per beneficiary recommended to avoid
co-payments i.e. Ampath,
Lancet and Pathcare
Specialised radiology
IVP tomography, contrast studies, MRI, bone 100% of NMS tariff Unlimited cover Yes, at least 72 hours prior to procedure –
densitometry for males and females younger than 50, R500 co-payment applicable to out- of-
CT scans, PET scans and related consumables hospital non-PMB conditions and not
applicable to PET scans
Bone densitometry for males and females older 100% of NMS tariff One per beneficiary per annum
than 50 No co-payment for out- of-hospital non-
PMB conditions
Mammogram 100% of NMS tariff One per beneficiary per annum
Any other specialised radiology 100% of NMS tariff Unlimited cover None –
Basic radiology
Black and white X-rays and ultrasonography 100% of NMS tariff Refer to the included Pocket Guide for the None (maternity ultrasounds require registration –
limit amount per family on the Maternity Care Programme)
Maternity benefit
Hospital and home confinements 100% of NMS tariff Unlimited cover Yes, registration on Maternity Care Programme At DSP
Ultrasound scans 100% of NMS tariff Two (2) ultrasounds –
Antenatal consultations at a Gynaecologist or 100% of NMS tariff 13 consultations Preferred Provider use
General Practitioner recommended to avoid
co-payments
Antenatal classes R1 000 per pregnancy at any Storks Nest facility At Storks Nest
Immunisations – Failure to make use of a DSP will result in payment from MSA
Baby and child immunisations (up to 12 years) 100% of NMS tariff Unlimited cover. According to Department None Vaccine – At DSP
of Health protocol including MMR vaccine
but excluding HPV vaccine Administration of vaccine
– At Storks Nest
Dentistry
Basic dentistry (fillings, extractions, X-rays and 100% of NMS tariff Combined in- and out-of-hospital dentistry None Preferred Provider
prophylaxis) and specialised dentistry (periodontics, limit, subject to Dental Managed Care use recommended to
bridgework, crowns, dentures and dental implants) Protocols minimise co-payments
Orthodontics (under 21 years of age) 100% of NMS tariff Refer to the included Pocket Guide for the Yes, treatment plan required
limit amount per familyService Benefit Limits (Subject to managed care Authorisation Requirements Designated service
rules and protocols) provider (DSP)/
Preferred provider
Maxillo-facial and oral surgeons performing 100% of NMS tariff Subject to Managed Care Rules and Yes
specialised dental procedures Protocols
In-hospital dentistry and maxillo-facial surgery: refer to in-hospital cover above
Prostheses
External and internal prostheses 100% of approved Subject to an annual limit and sub-limits Yes Preferred Provider
benefit per beneficiary per annum. No sub-limit for use recommended for
hip, knee and shoulder replacements and knee, hip and shoulder
prosthetic devices used in spinal surgery if replacements else sub-
a Preferred Provider is used. Refer to the limits will apply
Pocket Guide for details.
Appliances
Hearing aids and hearing aid repairs 100% of approved Subject to limit per beneficiary per ear Yes –
benefit every 2 years. Refer to the Pocket Guide
for details
Other appliances Subject to an annual limit per beneficiary. –
Refer to the Pocket Guide for details
Ambulance services
Air and road emergency services 100% of cost at None No authorisation required if DSP is utilised Through DSP Netcare
DSP 911
A 25% co-payment will apply for voluntary, non-emergency use of any other service provider.
Home nursing, step down / sub-acute, rehabilitation
Home nursing, step down, sub-acute (physical) 100% of NMS tariff Subject to Managed Care Rules and Yes As authorised
rehabilitation Protocols
Home nursing, hospice, end of life care
Advanced Illness Benefit for oncology patients 100% of NMS Subject to Managed Care Rules and Yes As authorised
tariff at approved Protocols
provider
Compassionate Care Benefit 100% of NMS Subject to Managed Care Rules and Yes As authorised
for other terminal illnesses tariff at approved Protocols
provider
HIV management
HIV treatment 100% of NMS tariff Unlimited cover, subject to formularies Registration on HIV/AIDS Wellness Programme –
Member savings account (MSA)
General practitioners
Consultations and all visits and procedures 100% of NMS tariff Subject to MSA balance – –
performed out-of-hospital or in the emergency
department
Prescribed acute medication
Acute medicine prescribed and or dispensed by 100% of NMS tariff Subject to MSA balance – –
medical practitioners or specialists
Self-medication or over-the-counter (OTC) medication
Homeopathic medicines, multi-vitamins, calcium,
magnesium, tonics, stimulant laxatives, contact lens
preparations
Optical
First optometric consultation will automatically be 100% of NMS tariff One consultation per beneficiary None Preferred Provider
paid from specialist visits per annum use recommended to
Subsequent optometric consultations 100% of NMS tariff Subject to MSA balance – minimise
co-payments
Spectacle lenses and frames, readers and contact 100% of NMS tariff Subject to MSA balance –
lenses
Hospital out patient visits
Out patient visits to the emergency department with 100% of NMS tariff Subject to MSA balance – –
non-PMB and non-priority emergency diagnoses
Auxiliary services
Psychology and social services: consultations, 100% of NMS tariff Subject to MSA balance – –
therapy, treatment and social workers
Physiotherapy out-of-hospital and biokinetics
Homeopathy, naturopathy, chiropractic, speech
therapy, audiology, occupational therapy,
acupuncture, podiatry and dietetics (excluding X-rays
and appliances)
Educational, remedial and marriage counselling No benefit No benefit – –SPECIAL FEATURES
Compassionate Care Benefit (CCB) alcohol addiction. Please contact the Client Contact Centre for
confidential support and a referral to an appropriate treatment
Through the Compassionate Care Benefit (CCB), Netcare facility should you be in need of assistance. Daily limits and
Medical Scheme aims to ensure that members with advanced annual limits apply and pre-authorisation is compulsory.
disease have access to comprehensive palliative care that
offers you or your loved one, quality care in the comfort of HIV/AIDS wellness programme
your own home, or in a hospice type facility, with minimum
disruption to your normal routine and family life. Palliative It has been demonstrated that by proactively managing HIV,
care is provided by nurses or care workers in partnership those who have been diagnosed as HIV positive can live a
with the Hospice Palliative Care Association of South Africa healthy and fulfilling life. When you register for our HIVCare
Registration is required to access this benefit. Programme you are covered for the care that you need. You
can be assured of confidentiality at all times.
Oncology – Advanced Illness Benefit (AIB) Call us on 0861 638 633 or email hiv@netcaremedicalscheme.co.za
to register.
Through the Advanced Illness Benefit (AIB), Netcare Medical
Scheme aims to ensure that members with advanced stages
of cancer have access to a comprehensive palliative care Emergency medical evacuations
programme facilitated by Discovery HomeCare. This is a
If you ever find yourself in a situation where you require
unique home-based service that offers you quality care in
emergency transport for medical reasons, you are in the very
the comfort of your own home, with minimum disruption to
best hands. The Netcare Medical Scheme ambulance benefits,
your normal routine and family life. Palliative care is provided
which are covered under insured benefits, include medically
by nurses or care workers in partnership with the Hospice
appropriate air and road response services provided by
Palliative Care Association of South Africa. Registration is
Netcare 911. This benefit is available by contacting 082 911.
required to access this benefit.
International travel cover
Maternity Care benefit
Only minor incidentals will be covered by the Scheme and
The Maternity Care benefit has been specially designed
we recommend that members purchase international travel
to enhance the Scheme’s maternity benefit for expectant
insurance with a reputable travel agent in order to ensure
mothers, helping to ensure a healthy, happy pregnancy.
comprehensive medical cover when abroad.
Expectant mothers are required to register on this programme
from the 12th week of their pregnancy. At registration, we will The Scheme will however reimburse members for treatment
provide you with a list of benefits available as well as any other based on the equivalent Netcare Medical Scheme tariff (in
South African Rands) for a medical service rendered as if the
information you may require.
service had been rendered within the Republic of South Africa.
There may be a substantial difference between South African
Substance abuse focus and international tariffs which may result in the member being
responsible for a significant shortfall.
All Netcare Medical Scheme members have access to South
African National Council on Alcoholism and Drug Dependence Members are required to settle all healthcare accounts in the
(SANCA) approved facilities as in-patients for drug and country of travel and to submit such claims to the Scheme
21upon return. It is important to understand that the Netcare Medical DiabetesCare programme (DCB)
Scheme membership card is not recognised by healthcare providers
outside of the borders of the Republic of South Africa and it will The DiabetesCare programme, together with your Premier
not be accepted by international agents and service providers. Plus GP, will help you, and your dependants, actively
The Scheme will permit members and beneficiaries on chronic manage diabetes. A Premier Plus GP is a network GP who
medication to have an extra month’s supply of chronic medication has contracted with us on a set of diabetes focused quality-
dispensed to them prior to departure, in cases where the journey based metrics.
is for a prolonged period. However, this must be arranged with The DiabetesCare programme is based on clinical and lifestyle
the Scheme by contacting the Client Contact Centre before the guidelines and has been designed to support patients in the
medication can be dispensed. management of diabetes. The programme gives you and
International travel cover does not include any form of your Premier Plus GP access to various tools to monitor and
repatriation that may be required. manage your condition and to ensure you have access to high-
quality coordinated care. You and your GP can track progress
Self service facilities on a personalised dashboard displaying your unique Diabetes
Management Score. This will help to identify the steps you
The Netcare Medical Scheme website has been specifically should take to manage your condition and stay healthy
developed for the benefit of members, and by registering over time. This programme also unlocks cover for valuable
on the site, you are able to review your monthly statements, healthcare services from healthcare providers like dietitians
claims and personal information on-line. and biokineticists. Members with diabetes who have registered
on the Chronic Illness Benefit (CIB) will be eligible to enrol on
To register, simply visit www.netcaremedicalscheme.co.za and
the DiabetesCare programme but you must make use of a
register by entering your membership number and identification
Premier Plus GP so please check if your GP is listed.
or passport number.
ADMINISTRATIVE REQUIREMENTS
Claims administration
In order to qualify for benefits a claim must be submitted to the Scheme not later than the last day of the fourth month following the
month in which the service was rendered. If you believe a claim has been rejected in error, you have 60 days to report the error and
resubmit the claim failing which the claim will be classified as stale.
As the member of the Scheme you are responsible for Members who pay cash for any services received should
monitoring and reviewing your monthly statement and remember to submit the claim with the receipt as proof of
for acting promptly where a claim is not reflecting, or payment using the appropriate contact details of the Scheme
has not been paid. This will ensure that such claims as provided in this Membership Brochure or communicated by
do not become stale. Claims submitted after they have the Scheme from time-to-time.
become stale will not be paid by the Scheme (in line Members will be reimbursed at the relevant Scheme Rate
with Regulation 6 of the Medical Schemes Act No. (refer to the Pocket Guide for details) and you may request the
131 of 1998). Scheme in writing for differences between claimed amounts
and benefit amounts to be settled from your Member Savings
Account (MSA).This can only be done if your MSA reflects a positive balance.
Members are responsible for ensuring that the Payment of claims is always subject to Scheme rules, tariffs,
Scheme is informed of any changes in their banking limits and Managed Care Protocols and Guidelines may apply.
details. Please note that changing your banking details
Remember to obtain pre-authorisation (refer to the Pocket
with your Human Resources (HR) Department does
Guide for the details of pre-authorisation requirements) at
not update your banking details with the Scheme.
least 72 hours prior to a planned event or within 72 hours
following an emergency.
Membership statements
Claims notification will be sent electronically where email details are available. Member statements will also be available on the
Scheme’s website www.netcaremedicalscheme.co.za
Member Savings Account (MSA)
All members contribute 15% of
On termination of membership,
You may give written instruction
their total monthly contribution into the Scheme may use your to the Scheme to fund any co-
their Member Savings Account. savings to offset any debt owed payments or shortfalls you may
For example, if your total Scheme by the member which may include be responsible for from your MSA.
contribution is R1 000, an amount outstanding contributions.
If you have savings available at
of R150 (15% of R1 000) will be
The Scheme advances six (6)
the end of the financial year (31
allocated to your savings and
months of savings to members December) your savings will be
R850 towards the risk pool.
effective 1 January and 1 July of carried over to the next year.
If you have a positive savings balance
each year. Overdrawn savings
In the unfortunate event of your
in your MSA at month-end you will (i.e. if you have used an amount
death, the savings balance due
receive interest on that amount. from your advanced savings that
to you will be transferred to your
exceeds the amount you have
If you resign from the Scheme
dependants in the event that they
contributed at the time of your
your savings balance will be decide to continue membership
resignation) will have to be repaid
kept for a four (4) month period of the Scheme or, in the absence
if you resign from the Scheme.
in order to settle any claims that of such dependants, paid into
were incurred before resignation. Payments from your MSA will be
your estate.
After the four (4) months, the done at 100% of the NMS rate subject
balance will be paid out to you or to funds being available at the date
transferred to your new medical on which a claim is processed.
scheme. If this pay-out occurs
before month-end, you will not
receive interest on the part-month.
23EXCLUSIONS
Unless prescribed as a minimum benefit or otherwise provided for or decided by the Netcare Medical Scheme Board of Trustees, expenses
incurred in connection with any of the following will not be paid by the Scheme:
Wilful self-inflicted injury except
Treatment required as a result of
Sterility and impotence examinations.
for PMBs. members’ or dependants’ use of
Cosmetic procedures including
any dependence-producing drugs
Holidays for recuperative purposes.
but not limited to gastroplasty, bat
or intoxicating liquor or the member
ears, blepharoplasty, dermabrasion,
Accommodation and services provided
being under the influence of any
lipectomy, breast augmentation
in a geriatric hospital, old age home, dependence-producing drugs except
and reduction, liposuction, nasal
frail care facility, or the like. for PMBs.
reconstruction, revision of scars
All costs of whatsoever nature
Treatment of obesity and slimming
and face lifts.
incurred for treatment of sickness preparations.
Vitamins, tonics and mineral supplements
conditions or injuries sustained by
The treatment of infertility and
not prescribed in conjunction with
a member or a dependant and for
artificial insemination, including an antibiotic or forming part of the
which any other party is liable.
all costs relating to sperm count maternity and HIV programmes.
The member is however entitled to
tests, in-vitro fertilisation, gamete Some vitamins that have a NAPPI
such benefits as would have applied
intrafallopian transfer, GIFT code may be procured from positive
under normal conditions, provided
procedures, zygote intrafallopian savings at a member’s discretion.
that on receipt of payment in respect
transfer (ZIFT) procedures, embryo
of medical expenses, the member will Illness, injury or disease arising from
transport, surrogate parenting, donor
reimburse the Scheme any money war, unrest or riots except for PMBs.
semen (and related costs including
paid out in respect of this benefit by
collection and preparation), and non- Appointments not kept.
the Scheme.
medically necessary amniocentesis
Injury or sickness caused by/or
Treatment consequential to medical
other than PMBs stipulated in the
treatment of alcohol or drug abuse,
procedures for which the Scheme Regulations to the Medical Schemes
unless registered with a SANCA
does not pay. Act, No. 131 of 1998.
approved programme or a PMB.
Expenses relating to, or incurred in
Interest and/or legal fees relating
Antenatal and post-natal classes
a research environment. to overdue medical accounts.
or post natal care at home unless
Medical examinations and tests for
Domestic and biochemical remedies.
registered on the maternity programme.
insurance or fitness purposes and
Exceeded annual or pro-rated limits.
Sunglasses and tinted lenses, unless
overseas visits.
the member requests this to be paid from
Patent foods or baby food, bandages,
Treatment of injuries arising
positive savings account balances.
cotton wool or similar aids,
from members and beneficiaries
sunscreen, shampoos and skin-
professionally participating in any
cleansing remedies.
sport or speed contests.
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