Standard Care Plan

Overview

The Standard Care Plan is a traditional medical plan with defined benefits and Out of Hospital Family Limits.

Out of hospital benefits are limited and grouped by service under individual limits. Unless it is a Prescribed Minimum Benefit (PMB), all benefits are paid at 100% of the Scheme Reimbursement Rate (SRR):

  • The SRR is based on the previously negotiated rate between medical schemes and providers
  • Providers are entitled to charge above the SRR
  • Members are encouraged to request the actual costs of services before purchasing them and to compare with the SRR
  • Obtain a quotation from your provider and call 0860 222 633 to receive an estimate of the SRR
  • Members may negotiate a better rate with their provider

Hospital cover is unlimited and paid at 100% of SRR.

Contributions 2019

Member Adult dependant Child dependant
R2 470 R2 470 R745

Standard Care Plan limits

In Hospital

General hospital services
Radiology and Pathology
unlimited, paid at 100% SRR

+

Internal surgical prostheses
R63 130 per beneficiary

Out of Hospital

Overall Out Of Hospital
Family Limit

Adult: R5 070
Child: R2 530

Sublimit 1
Alternative and allied healthcare
 

Adult: R3 275
Child: R685

Sublimit 2
Consultations, acute medication and Pharmacist Advised Therapy (PAT)

Adult: R4 760
Child: R2 380

+

Additional basic and specialised
Dentistry Family Limit
Adult: R1 325 / Child: R330

+

Radiology Family Limit
Adult: R1 680 / Child: R1 015

+

Pathology Family Limit
Adult: R1 285 / Child: R460

+

Medical and Surgical Appliances
R9 030 per family

+

Chronic medicine (non-PMB)
R4 370 per beneficiary

Example

How to calculate your Family Limit

Adult
R1 000
x 2 = R2 000
Child
R200
x 1 = R200
Family Limit
R2 200

Use the combined available limit for one or more family member or treatment

Your benefits

Ambulance service

Anglo Medical Scheme works with Netcare 911, our Designated Service Provider (DSP), to provide medical road and air ambulance emergency assistance at no cost to you.

Find out more
Cancer treatment

The Standard 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

Standard Care Plan members have access to an Overall Out Of Hospital Family Benefit, limited to R5 070 per adult and R2 530 per child per year.

This benefit has two sublimits. This sublimit applies to GPs and specialists in rooms.

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Dentistry

The Scheme has contracted the Dental Risk Company (DRC) to provide a range of basic dental services at an agreed network rate. Members visiting a network provider will not have to pay upfront or experience co-payments when receiving these services.

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Diabetes

We cover diabetes mellitus types 1 and 2 under Prescribed Minimum Benefits (PMBs). However, diabetic members on the Standard 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

Standard Care Plan members have a benefit of R380 per beneficiary for eye examinations and R2 100 per family for lenses and frames. As a member of Anglo Medical Scheme you qualify for discounts when visiting a Discovery Optometry Network provider.

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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. Call Anglo Medical Scheme's Call Centre on 0860 222 633 for authorisation.

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Maternity

Anglo Medical Scheme offers Standard 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 8 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 and Surgical Appliances

The following medical appliances are funded on the Standard Care Plan, subject to the annual Family Limit of R9 030 for Medical and Surgical Appliances per year:

  • Hearing aids
  • Wheelchairs
  • External appliances provided by orthotists and prosthetists
Find out more
Medicine

The Standard Care Plan covers medicine for acute and chronic conditions. Chronic medication is provided for Prescribed Minimum Benefits (PMB) and a set of additional non-PMB chronic conditions.  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 Standard Care Plan you have access to treatment for alcohol and drug treatment, hospice care, kidney disease treatment, organ transplant benefits, oxygen therapy, pathology and radiology services and cancer screening tests.

Find out more

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

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

Benefit information on this website is a summary of the registered Scheme Rules. In case of discrepancies the Rules shall prevail.

Authorisation

Elective admissions

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

Please phone us before the event on 0860 222 633 to receive authorisation for:

  • Specialised conditions (cancer/renal disease)
  • Hospitalisation
  • Specialised radiology (mammogram, bone density scan, MRI, CT scans)
  • Medicines: non-PMB chronic condition and PMB chronic conditions
  • Medical and surgical appliances exceeding R1 000
  • Maternity programme
  • Oxygen therapy
  • Rehabilitation and sub-acute care
  • Specialised procedures in day clinics and doctors' rooms

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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