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Standard Care Plan

Overview

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

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 in network facilities.

Contributions 2020

Member Adult dependant Child dependant
R2 705 R2 705 R815

Contributions subject to underwriting.

Your benefits

Ambulance service

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 Standard Care Plan offers you access to an Oncology management programme to assist with the management of cancer.You will have an oncology benefit of R300 000 per beneficiary, over a 12-month period.

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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 325 per adult and R2 655 per child per year.

This benefit has two sublimits for the different types of healthcare providers and acute medicine.

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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 R400 per beneficiary for eye examinations and R2 205 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 of the Standard Care Plan have access to facilities on the Scheme’s Hospital Network for planned admissions. Ensure your specialist works from a day clinic, facility or hospital on the network. Planned admissions must be authorised. Call us on 0860 222 633 for authorisation and to find a facility on the Hospital Network.

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Maternity

Register on the maternity management program between week 12 and 20 of the pregnancy to qualify for in and out of hospital maternity benefits, provided by qualified professional to assist you through your pregnancy and confinement. Call 0860 222 633 for registration.

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Medical and Surgical Appliances

The following medical appliances are funded on the Standard Care Plan, subject to the annual Family Limit of R9 480 for Medical and Surgical Appliances per year:

  • Hearing aids
  • Wheelchairs
  • External appliances provided by orthotists and prosthetists
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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.

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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.

The Scheme will pay 80% of SRR, subject to Scheme protocols. 20% to be paid as co-payment by member.

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 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?

General exclusions

The following are some of the Scheme exclusions (for a full list please refer to the Rules). These you would need to pay:

  • Services rendered by any person who is not registered to provide healthcare services, as well as medicine that have been prescribed by someone who is not registered to prescribe
  • Experimental or unproven services, treatments, devices or pharmacological regimes
  • Patent and proprietary medicines and foods, including anabolic steroids, baby food and baby milk, mineral and nutritional supplements, tonics and vitamins except where clinically indicated in the Scheme’s managed care protocols
  • Cosmetic operations, treatments and procedures, cosmetic and toiletry preparations, medicated or otherwise
  • Obesity treatment, including slimming preparations and appetite suppressants
  • Examinations for insurance, school camps, visas, employment or similar
  • Holidays for recuperative purposes, regardless of medical necessity
  • Interest or legal fees relating to overdue medical accounts
  • Stale claims, which are claims submitted more than four months after the date of treatment
  • Claims for appointments that a member fails to keep
  • Costs that exceed any annual maximum benefit and costs that exceed any specified limit to the
  • benefits to which members are entitled in terms of the Rules
  • All costs related to:
    • Anaesthetic and hospital services for dental work (except in the case of trauma (PMB), patients
    • under the age of seven years and the removal of impacted third molars)
    • Bandages, dressings, syringes (other than for diabetics) and instruments
    • Lens preparations
    • DNA testing and investigations, including genetic testing for familial cancers and paternal
    • testing
    • Gum guards, gold in dentures and in crowns, inlays and bridges
    • Immunoglobulins except where clinically indicated against the Scheme’s protocols
    • In vitro fertilisation, including GIFT and ZIFT procedures, and infertility treatments which are not PMBs
    • Organ donations to any person other than to a member or registered dependant
    • Wilful self-inflicted injuries.

General Rule reminders

  • Benefit information on this website is a summary of the 2020 benefits.
  • Find the full set of registered Rules here.
  • The Anglo Medical Scheme Rules are binding on all beneficiaries, officers of the Scheme and on the Scheme itself
  • The member, by joining the Scheme, consents on his or her own behalf and on behalf of any
  • registered dependants, that the Scheme may disclose any medical information to the administrator for reporting or managed care purposes
  • A registered dependant can be a member’s spouse or partner, a biological or stepchild, legally
  • adopted child, grandchild or immediate family relation (first-degree blood relation) who is dependent on the member for family care and support
  • To avoid underwriting, a member who gets married must register his or her spouse as a dependant within 30 days of the marriage. Newborn child dependants must be registered within 30 days of birth to ensure benefits from the date of birth
  • If your dependant reaches the age of 23 and you wish to keep him or her on the Scheme as an adult dependant, you may apply for continuation of membership
  • It is the member’s or dependant’s responsibility to notify the Scheme of any material changes, such as marital status, banking details, home address or any other contact details and death of a member or dependant.
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