Managed Care Plan 

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

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

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.

Anglo Medical Scheme offers a Disease Prevention Programme designed to support members who are at risk of developing diabetes, to improve health outcomes and quality of life. Whether you are at risk and eligible to join the programme depends on results of your health check assessments.

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.

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.

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.

The Eye Care Benefit on Managed Care Plan includes Lenses, frames and refractive surgery limit of R4 230 per family per year and R470 for an eye examination per beneficiary per year.

This includes consultations, lenses, frames, contact lenses and surgery (for cosmetic purposes) or any health care service to correct refractive errors of the eye, like excimer laser. Upon depletion of the Optical benefit and the eye examination limit, claims will automatically be paid from available funds in your Medical Savings Account.

Claims paid from the Optometry Benefit are reimbursed at the Scheme Reimbursement Rate. Should you wish to have the excess paid from your Medical Savings Account, you need to complete the "MSA Exception Form" in every instance.

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.

Medically related frail care services where clinically appropriate will be funded according to Scheme protocols. A limit of R82 455 per beneficiary applies. Only claims received from facilities with a registered GHF practice number or services provided at home by a nurse practitioner with a registered BHF practice number 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.

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.

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 (up to the price of 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.

These are external appliances provided by a Discovery Health network of orthotists and prosthetists. The Medical and Surgical Appliance Family Limit is R18 750. Authorisation is required for appliances over R3 000 each. You are responsible for the difference in cost when using a non-DSP.

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.

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.

All medical schemes in South Africa have to include the Prescribed Minimum Benefits in the plans they offer to their members.

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.

This benefit applies to a specified list of specialised medicine (excluding oncology medicine) in excess of R5 630 per month and specialised technology in excess of R5 630 per item as a once off purchase, subject to authorisation.

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.

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.