Day-to-Day Medical Expenses
Claims are paid from the member's savings account (MSA)
A fixed amount is allocated to your MSA for 12 months in the year. The total allocation for the year is made available at the beginning of the year if you are registered from 1 January. Should you join during the course of a year, the amount in your MSA will be prorated according to the number of months during that year that you are a member of the Scheme.
If you have funds available in your MSA at the end of the year, this amount will be carried over and added to your savings balance for the following year. Being careful with your MSA funds will enable you to build up a considerable savings account over time. If you resign from the Scheme during the course of the year, any money remaining in your MSA will only be paid out after four months. This time lapse ensures that all your claims will be paid. If you join another medical scheme that has a savings account option, your remaining funds will be transferred to your new medical scheme.
Should you resign from the Scheme during the year and have already spent the entire MSA amount for the year, you will be required to repay the difference between the total amount spent and the benefit entitlement due to the Scheme on your date of termination. Your savings account is administered by the Scheme; however, you have full control over how you spend the funds in your MSA.
The MSA can be used to cover
- Acute and OTC medication
- Chiropody and podiatry
- Clinical psychology
- Dentistry co-payments
- Optometry co-payments
- General practitioner (GP) and some specialist consultations (visit in rooms and at emergency facilities)
- Homeopaths and naturopaths (including medication)
- Out-of-hospital care
- Physiotherapy (out of hospital)
- Social and other auxiliary services
- Speech and occupational therapy
Should your healthcare provider charge Scheme rates, the Scheme will pay him or her directly - unless you have paid the account upfront and have included a receipt with your account. If your healthcare provider charges private rates (more than the Scheme rate), you need to settle the account directly with the healthcare provider, whereupon the Scheme will reimburse you with the appropriate benefit at the Scheme rate. The MSA cannot be used to pay for PMBs, including co-payments relating to PMBs.
Except in an emergency, prior to admittance to a hospital, a pre-authorisation is required.
Courier pharmacy for Chronic Medication
Preferred Provider Negotiators (PPN), South Africa's largest optometric network, provides members with enhanced optometry benefits on behalf of the Scheme. PPN has agreements with more than 2 300 optometrists throughout South Africa