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Managed Care Plan


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% allocated to savings, for discretionary spend.
  • 79% allocated to limited/unlimited benefits
    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 2022

Contributions (excluding savings)
Member Adult dependant Child dependant
R4 305 R4 305 R995
Member Adult dependant Child dependant
R1 145 R1 145 R265
Total contribution (including savings)
Member Adult dependant Child dependant
R5 450 R5 450 R1 260

*2022 benefits and contributions are subjected to the approval of the Council for Medical Schemes.

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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The Covid-19 benefit covers out-of-hospital management and supportive treatment. This benefit funds the Covid-19 Prescribed Minimum Benefit (PMB) as well as additional Scheme benefits as long as it meets the Scheme's clinical and benefit entry criteria. Hospitalisation for Covid-19 is funded from the hospital benefit.

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Day Clinics

Day clinics are healthcare facilities that provide surgical services and diagnostic procedures performed in an operating theatre on a same-day basis. They offer convenient alternatives to overnight hospital stays. Avoid co-payments for procedures such as endoscopies and cataract surgery done in day clinics instead of hospital.

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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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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 R73 040 per beneficiary applies. Only claims received from registered facilities or services provided at home by a registered nurse practitioner will be considered for payment.


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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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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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.

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 610. 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

A Medical Savings Account (MSA) holds the funds that you can use to pay for a set list of healthcare services and products, such as procedures, medicine, consultations and more. Each January, you receive an advance allocation for the year. A portion of your monthly contribution is then used to pay this back to the Scheme every month. During the year you have the flexibility to use the funds in your MSA as you need them. Any MSA funds still available in your account at the end of the year will roll over to the next year. Savings carried over 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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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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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.

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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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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