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Managed Care Plan

Overview

Managed Care Plan offers the following comprehensive benefits:

  • Unlimited hospital cover paid at 100% of the Scheme Reimbursement Rate (SRR)
  • The Top-Up rate pays up to a maximum of 230% of the SRR for specialist services in hospital, excluding pathology, radiology, allied healthcare services and GPs performing specialist services (230% = 100% SRR + additional 130% of SRR)
  • A Medical Savings Account for out of hospital services and discretionary spend
  • Unlimited Radiology and Pathology
  • Frail care where clinically required
  • Extensive chronic medication
  • Voluntary use of a GP network (no co-payments)
  • Reimbursement for specialist consultations and procedures out of hospital up to 125% of SRR

Contributions are split as follows:

  • 21% goes towards savings, for discretionary spend.
  • 79% goes towards the Hospital Benefit or major medical benefit
    This category of benefit provides cover for procedures over which members have little or no control and includes benefits such as:
    • Prescribed Minimum Benefits (PMBs)
    • Non-PMB Chronic medicine subject to authorisation
    • Cancer, diabetes and kidney treatment, subject to registration on the disease management programmes.

Contributions 2020

Contributions (excluding savings)
Member Adult dependant Child dependant
R3 905 R3 905 R905
Savings
Member Adult dependant Child dependant
R1 040 R1 040 R240
Total contribution (including savings)
Member Adult dependant Child dependant
R4 945 R4 945 R1 145

Your benefits

Ambulance services

Netcare 911, our Designated Service Provider (DSP), provides medical road and air ambulance emergency assistance at no cost to you.

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Cancer treatment

The Managed Care Plan offers you access to an Oncology management programme to assist with the management of cancer. Registration is compulsory.

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Consultations and procedures out of hospital

Consultations and procedures out of hospital can be provided by GPs or specialists in their rooms for acute or chronic conditions. Find out which services are paid by the Scheme and which from available savings in your MSA.

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Dentistry

The Dentistry Benefit on the Managed Care Plan includes conservative treatments, including fillings, x-rays, extractions and oral hygiene. Specialised treatments including crowns, bridges, inlays, study models, dentures, orthodontics, osseo-integrated implants or similar tooth implants and periodontics.

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Diabetes

We cover diabetes mellitus types 1 and 2 under Prescribed Minimum Benefits (PMBs). However, diabetic members on the Managed Care Plan have to register with the contracted Designated Service Provider (DSP), Centre for Diabetes and Endocrinology (CDE), to enable effective management of their condition.

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Eye Care

Eye examinations, lenses, frames, contact lenses are paid at 100% of cost from available funds in your Medical Savings Account savings account.

Members will not have a co-payment when cataract surgery with intra-ocular lens replacement is performed out-of-hospital. Top-Up rate up to 230% of SRR for specialist services or in full if PMB.

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Frail care

Medically related frail care services where clinically appropriate will be funded according to Scheme protocols. A limit of R70 710 per beneficiary applies. Only claims received from registered facilities or services provided at home by a registered nurse practitioner will be considered for payment.

HIV/AIDS

Anglo Medical Scheme offers HIV-positive members and their dependants a confidential management programme, aimed at keeping them well and providing access to increased benefits to help manage their condition more effectively.

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Hospitalisation

Members must authorise planned hospital admissions. Most hospitals require benefit confirmation before admission, and completing Anglo Medical Scheme's simple authorisation procedure will prevent any delay at the time of admission.

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Maternity

Anglo Medical Scheme offers Managed Care Plan members a maternity management programme with additional benefits. Qualified professionals will assist you through your pregnancy and confinement.

Registration on the maternity management programme is compulsory to ensure payment from the correct benefit.

You need to register between weeks 12 and 20 of the pregnancy, please phone 0860 222 633.

Consultations and ultrasound scans
The maternity benefit includes 12 consultations and 2 ultrasound scans (2D) per pregnancy.

Confinement
You can deliver your baby in hospital or, if preferred, in a low-risk maternity unit provided by a registered midwife. Call us on 0860 222 633 for authorisation prior to delivery.

Medical Appliances

These are external appliances provided by a Discovery Health network of orthotists and prosthetists. The Medical and Surgical Appliance Family Limit is R16 080. Authorisation is required for appliances over R3 000 each. You are responsible for the difference in cost when using a non-DSP.

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Medical Savings Account

The annual Medical Savings Account (MSA) allocation is made available to you in January (in advance for the year) and offers the flexibility to pay for a set list of procedures, medicine, services, etc. Any unspent savings belong to the member and roll over to the next year. Positive savings carried forward from previous years allow you to build up a healthy savings balance for a time when you need extra medical cover.

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Medicine

The Managed Care Plan offers rich benefits for chronic medicine. Acute medicine, homeopathic and Pharmacist Advised Therapy (PAT) medicine will be paid at 100% of the Single Exit Price (SEP) from your MSA. The Scheme has a dedicated medicine management team to help you reduce out-of-pocket expenses for medicine and to manage your chronic medicine benefits.

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Preventative care

To support you in managing your health proactively, we encourage you to take preventative measures. Detecting health risks or a disease early could prevent a disease, or at least improve the success rate of the treatment.

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Other benefits

If you are on the Managed Care Plan, you have access to alcohol and drug treatment, hospice care, kidney disease treatment, organ transplant benefits, oxygen therapy, pathology, radiology and cancer screening tests.

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Specialised Medicine and Technology

This benefit applies to a specified list of specialised medicine (excluding oncology medicine) in excess of R5 000 per month and specialised technology in excess of R5 000 per item as a once off purchase, subject to authorisation.

Disclaimer: All benefits paid at 100% of Scheme Reimbursement Rate (SRR), negotiated rate or at cost if PMB. Tariffs available from the Call Centre if a quote is provided.

Familiarise yourself with the most important Scheme exclusions and Rule reminders.

Benefit and contribution information on this website is a summary of the registered Scheme Rules, subject to the approval of the Council for Medical Schemes. In case of discrepancies the Rules shall prevail.

To obtain authorisation

Procedures, treatments, hospitalisation, external medical or surgical appliances, specialised radiology

To access benefits and to ensure they are available and correctly paid, call 0860 222 633 to get authorisation before the event as indicated in the benefit table, for

  • procedures,
  • treatments,
  • hospitalisation,
  • specialised radiology,
  • internal surgical prostheses and
  • external medical appliances exceeding R3 000

Elective admissions need to be authorised 48 hours before the event. Emergency admissions require authorisation the next working day after the event.


Information required when calling for authorisation:

  • Membership number
  • Date of admission
  • Name of the patient
  • Name of the hospital
  • Type of procedure or operation, diagnosis with CPT code and the ICD-10 code (obtainable from the doctor)
  • The name of your doctor or service provider and the practice number

This authorisation number must be quoted on admission. It will be valid for a period of four months or until the end of the year, whichever comes first. Please phone 0860 222 633 if any of the details change such as the date of operation, procedure etc. If the admission is postponed or not taken up before it becomes invalid, a new authorisation number will need to be obtained.

How to claim

Who submits the claim to the Scheme?

Your healthcare provider can either submit the claim to the Administrator directly, or you may have to settle the account first and then submit the claim to the Administrator yourself.

Whether you or your healthcare provider submit the claim, you remain responsible for payment of the healthcare services.

How do I submit a claim to the Scheme?

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