Netcare Medical Scheme Member Brochure 2018

 
Netcare Medical Scheme Member Brochure 2018
Netcare Medical Scheme
       Member Brochure 2018

CARE | DIGNITY | PARTICIPATION | TRUTH | PASSION
Netcare Medical Scheme Member Brochure 2018
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
Netcare Medical Scheme Member Brochure 2018
Netcare Medical Scheme Member Brochure 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
Netcare Medical Scheme Member Brochure 2018
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
Netcare Medical Scheme Member Brochure 2018
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
Netcare Medical Scheme Member Brochure 2018
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
Netcare Medical Scheme Member Brochure 2018
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
Netcare Medical Scheme Member Brochure 2018
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
Netcare Medical Scheme Member Brochure 2018
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:

                                                                     8
Monthly 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

                                                                9
STRUCTURE 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 years
Expenses 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.

11
Important 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

                                                                  12
Some 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

                                                                          13
BENEFITS

              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.

14
Authorisation – 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.

                                                                      15
Use 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

                                                                   16
How 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.

                                                              17
NETCARE 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-DSP
Service                                                 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 family
Service                                                  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            Yes                                                       –
                                                                                     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

                                                                     21
upon 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.
                                                                     23
EXCLUSIONS

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.

                                                                  24
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