Important concepts to understand

The terms and concepts mentioned below are to help you understand your membership a bit more. Please keep in mind some of the abbreviations and explanations when you come across them at some point when we refer to membership descriptions and benefits.

About Prescribed Minimum Benefits (PMB)

 

Prescribed Minimum Benefit conditions

In terms of the Medical Schemes Act of 1998 (Act number 131 of 1998) and its regulations, all medical schemes have to cover the costs related to the diagnosis, treatment and care of:

  • Any life-threatening emergency medical condition 
  • A defined set of 270 diagnoses and
  • 26 chronic conditions.

These conditions and their treatments are known as the Prescribed Minimum Benefits (PMB). 

All medical schemes in South Africa have to include the Prescribed Minimum Benefits in the health plans they offer to their members. There are, however, certain requirements that a member must meet before he or she can benefit from the Prescribed Minimum Benefits. 

The three requirements are: 

  1. The condition must be part of the list of defined PMB conditions
  2. The treatment needed must match the treatments in the defined benefits on the PMB list
  3.  Members must use the scheme’s designated healthcare service providers.

Prescribed Minimum Benefits additional links

Appeal for out-of-hospital treatment

Guide to Prescribed Minimum Benefits 

Guide to transplant claims submission process

Out-of- hospital Management of a PMB 

 

Member Savings Account

This is an amount that gets set aside for you with 50% allocated in January and 50% allocated in July. You can use it for day-to-day healthcare expenses like doctor’s visits, optometry and medicine.

Chronic Medicine

The Chronic Illness Benefit covers approved medicine for the 26 Prescribed Minimum Benefit (PMB) Chronic Disease List (CDL) conditions. We will fund approved medicine on the medicine list (formulary) in full up to the Scheme rate. Medicine not on the medicine list will be funded up to the Maximum Medical Aid Price (MMAP).

You have further cover for a non Chronic Disease List condition. There is no medicine list for this condition. We will fund approved medicines for this condition up to the Maximum Medical Aid Price (MMAP). There is an annual limit that applies to approved medicine for this condition.

If you want to access cover from the Chronic Illness Benefit, you must apply for it. You must complete a Chronic Illness Benefit application form with your doctor and summit it for review. You need to meet the benefit entry criteria for your condition to be registered on the Chronic Illness Benefit.

If your Chronic Disease List (CDL) condition is approved, the Chronic Illness Benefit will cover certain tests, procedures and consultations for the diagnosis and ongoing management of the condition in line with Prescribed Minimum Benefits.

Documents for your Chronic Illness Benefit (CIB) cover:

Chronic Illness Benefit application form (253 kb ) 

Chronic Illness Benefit medicine list (formulary) (2.08 mb ) 

Netcare Scheme rate

This is a rate set by the Netcare Medical Scheme at which claims and services for healthcare providers (hospitals, pharmacies and healthcare professionals) will be paid.

Limits

Most in- and out-of-hospital healthcare benefits are unlimited, but there are some healthcare services such as dentistry and radiology that are subject to annual limits. It is important for you to familiarise yourself with these limits and to track your usage. Netcare Medical Scheme members are able to do so via the website after logging in.

Hospital cover

This is the cover you get when you are admitted to hospital for emergency and planned hospital admissions. You have to get authorisation from us for your hospital stay. Your hospital cover is made up of your hospital account and related accounts. A related account is an account from your treating doctor, anaesthetist and any other approved healthcare services like pathology or radiology scans.

Day-to-day cover

Day-to-day cover includes your visits to healthcare professionals out of hospital, radiology, pathology and medicines purchased for everyday use. We cover your day-to-day healthcare services from the Member Savings Account (MSA) and the Insured Benefit, depending on the healthcare service you are using.

 

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