Benefit changes for 2018

Most benefit limits for 2018 will increase to accommodate yearly inflation and cost increases.

1. We are introducing home-based services for wound care, end-of-life care, IV infusions (drips) and postnatal (after birth) care that the Scheme will pay for from the Major Medical Benefit. This means you do not use your day-to-day benefits to pay for home-based care services. However, you must use the services of the Scheme’s Designated Services Provider and get authorisation.

2. If you have or are diagnosed with cancer and register on the Oncology Programme, your oncology case manager will tell you who we have an agreement with to provide cancer medicine in your area. If you get your approved medicine from them, the Scheme will pay for it in full. If you get the medicine from a pharmacy we do not have an agreement with, you have to pay 20% of the medicine cost yourself.

3. If you need a device for your hip or knee replacement (device for a major joint replacement), the Scheme will pay for the device in full if you get it from a provider we have an agreement with. If you do not get the device from one of the Scheme’s Designated Service Providers, a limit of R30 000 will apply. We have identified certain hospitals as DSP providers for these procedures. If another, non-DSP hospital is used, a 20% co-payment will apply to the hospital costs, which you will have to pay from your own pocket.

4. If basic screening tests show you possibly have diabetes or high cholesterol, advanced testing must be done. The Scheme will pay for the HbA1c blood test or LDL cholesterol test from the Screening Benefit if you meet the clinical entry criteria.

5. The Scheme will also pay for more frequent Pap smears and mammograms (breast X-rays), and a once-off BRCA gene test for members at risk of developing breast cancer.