l Frequently Asked Questions

While both options cover for your routine, day-to-day and major medical expenses, there are various sub-limits for Day-to-day Benefits on the Essential Option.

The Comprehensive Option offers a Medical Savings Account (MSA) whereas the Essential Option does not. Savings can be used for expenses such as the member portion, co-payments and medical expenses not covered by the Scheme, for example over-the-counter medicine (pharmacy-advised therapy).

Both Options offer a special Wellness Benefit for preventive care and early detection.

The Essential Option has an Overall Annual Limit per family, whereas the Comprehensive Option does not have an Overall Annual Limit.

Who can join SAB Medical Aid?

Membership of SAB Medical Aid is restricted to full-time, permanent employees of South African Breweries (SAB), and participating employers.

Who can I add as a dependant on my SAB Medical Aid membership?

Legal dependants can include a member’s spouse or partner, dependent children, stepchildren or children in the member’s legal custody, including dependent grandchildren. A member’s adult child can remain registered on the Scheme if they are full-time students and/or are financially dependent on the member. For example, a mentally or physically disabled child who is not employed can be a dependant, as well as financially dependent parents or parents-in-law who earn less than a certain amount.

What happens if I get divorced?

If you divorce or end a domestic partnership, your ex-spouse or ex-domestic partner can no longer remain a dependant on your membership. Kindly inform us in the event of a divorce or ending a domestic partnership so that your ex-spouse or ex-partner as your dependant could be removed. If we unknowingly pay their claims, you may have to pay the cost of those claims back to the Scheme. Please speak to your People Department to remove a dependant.

Can my children remain registered dependants on the Scheme when they turn 19 years or older?

If your child is turning 19 years or older and is a registered dependant on your membership, you need to submit proof that they qualify to stay on your membership before their birthday, if you want them to remain a registered dependant.

Your child will qualify as a dependant if they are a full-time student and/or are dependent on you for family care and support. The proof can either be a sworn affidavit indicating that the dependant is not employed full time, or for a full-time student, proof of registration from the institution where they are enrolled.

If you do not submit the required proof, your child dependant’s membership will automatically end at the beginning of the month following their birthday. You need to provide yearly proof of dependency from the time your child turns 19 years.

What happens to my dependants when they turn 21?

All dependants who are 21 years and older, their contributions are charged at adult dependant rates, with the exception of disabled children, who are charged child dependant rates until they turn 26.

To keep dependants who are not disabled registered on your membership, we require yearly verification of either full-time studies or a sworn affidavit indicating that the dependant is not employed full time. You must send this information to confirmation@sabmas.co.za. If you do not do this, your dependant’s membership will end.

Will I be charged a late-joiner penalty?

The Medical Schemes Act No 131 of 1998 allows medical schemes to impose a penalty (an additional fee) on late joiners. A late joiner is any member or adult dependant older than 35 years who has not had medical scheme cover for a number of years. Late-joiner fees discourage people from joining a medical scheme only when they’re old or sick, which is not fair to existing members who have contributed for many years.

How are late-joiner fees calculated?

A late-joiner fee is calculated as a percentage of the risk portion of your medical scheme contribution and does not include the savings portion of the contribution (where applicable). The additional fee that is charged depends on the number of years a person has not been covered by a medical scheme.

This is calculated as follows:

Age when applying minus (35 years + creditable cover*) = total years without cover**

*Creditable cover is medical cover the member had while they were over the age of 21 and only relates to registered South African medical schemes. In other words, cover on foreign schemes and cover as a dependant under the age of 21 is not recognised as creditable coverage.

**The total years without cover are matched to the maximum penalty that can be charged to determine the amount of the late joiner penalty. Schemes can determine the level of penalty and don’t have to charge the maximum but cannot charge more than the maximum.

The following example shows how a late-joiner fee works:
Thabo is 48 years old. He joined his company’s medical scheme at the age of 21 years and remained a member on that scheme for 10 years. He then moved overseas and was not a member of a South African medical scheme for 17 years. He recently returned to the country to work for SAB and will join SAB Medical Aid.

Thabo is a late joiner. His late joiner fee will be calculated as follows: 48 (Thabo’s current age) minus (35 years + 10) = three years uncovered.

According to the table, three years without cover equals a 5% late-joiner penalty. SAB Medical Aid may request Thabo to pay an additional 5% on his monthly contribution in fees. So, as a late joiner, Thabo may be required to pay up to 5% more than other members of SAB Medical Aid.

What are compulsory savings?

Compulsory savings only apply to members on the Comprehensive Option. If you are on the Comprehensive Option, an amount will be allocated to your Medical Savings Account every quarter. This amount will be 10% of your total contribution (member plus dependants) for the year, as shown in your latest Comprehensive Option contribution tables.

Here is an example on how we allocate your MSA:

If your yearly MSA is R1 200, then you will receive:

• R300 on 1 January
• R300 on 1 April
• R300 on 1 July
• R300 on 1 October

What are Prescribed Minimum Benefits (PMBs)?

Prescribed Minimum Benefits (PMBs) is a set of defined benefits for certain medical conditions that all medical schemes must provide according to the Medical Schemes Act. This ensures that all members have access to certain minimum healthcare services, regardless of their benefit option. The conditions that are covered as Prescribed Minimum Benefits were selected because they are common and often life threatening. Although these benefits must be provided to all members, SABMAS can apply certain clinical criteria to your treatment and ask you to use a designated service provider (DSP). Click here if you have questions about Prescribed Minimum Benefits.

Why are Designated Service Providers (DSPs) important?

A Designated Service Provider is a Healthcare Provider (such as a doctor, pharmacist or hospital) the Scheme has a payment arrangement with. In the case of Prescribed Minimum Benefits, Designated Service Providers are the Scheme’s first choice when members require diagnosis, treatment or care for a Prescribed Minimum Benefit condition. The Scheme appoints Designated Service Providers so that the treatment received for PMB conditions is appropriate and delivered at a reasonable cost.

What information is required for a claim to be considered for payment?

For quick and successful claim processing, the claim should include the following:

• Name
• ID number or patient’s date of birth
• Membership number
• Doctor’s practice number
• Date of service
• ICD-10 code
• Tariff code
• Amount charged.

What is the process leading up to the payment of a claim?

• The membership number is verified
• The patient’s information is verified
• The claim is captured
• The claim is assessed and verified against the benefit rules
• The claim is rejected or approved for payment.

What happens if information on my claim is missing or unclear?

If information that should be on a claim is missing or unclear, we reject the claim. The “Reason code” column on your claim statement will indicate the reason for the rejection. For example, Reason code 59 means the tariff code was either incorrect or was not supplied. If the reason for not paying the claim is a lack of information, get the right information and resubmit the claim.

What do the reason and pay codes on my claims statement mean?

The reason codes tell you more about the claim that was paid; for example, that it was paid from the Chronic Medication Benefit. If the claim was not paid, the reason codes will indicate why it was not paid. It is important to read the description we provide for every reason code on your claims statement, as you may be required to submit additional information before we can pay the claim.

What are ICD-10 codes and why are they important?

ICD-10 codes appear on your healthcare providers’ accounts. ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems. The ICD-10 codes tell us about the condition you’re being treated for, so the Scheme can settle claims correctly. The Medical Schemes Act requires medical schemes to treat all information about members’ conditions with the utmost confidentiality. The ICD-10 codes for your diagnosis will never be shared with anyone else, including your employers or family members.

Questions About Pre-Authorisation

What are Prescribed Minimum Benefits (PMBs)?

Prescribed Minimum Benefits (PMBs) is a set of defined benefits for certain medical conditions that all medical schemes must provide according to the Medical Schemes Act. This ensures that all members have access to certain minimum healthcare services, regardless of their benefit option. The conditions that are covered as Prescribed Minimum Benefits were selected because they are common and often life threatening. Although these benefits must be provided to all members, SABMAS can apply certain clinical criteria to your treatment and ask you to use a designated service provider (DSP). Click here if you have questions about Prescribed Minimum Benefits.

Why are Designated Service Providers (DSPs) important?

A Designated Service Provider is a Healthcare Provider (such as a doctor, pharmacist or hospital) the Scheme has a payment arrangement with. In the case of Prescribed Minimum Benefits, Designated Service Providers are the Scheme’s first choice when members require diagnosis, treatment or care for a Prescribed Minimum Benefit condition. The Scheme appoints Designated Service Providers so that the treatment received for PMB conditions is appropriate and delivered at a reasonable cost.

What information is required for a claim to be considered for payment?

For quick and successful claim processing, the claim should include the following:

• Name
• ID number or patient’s date of birth
• Membership number
• Doctor’s practice number
• Date of service
• ICD-10 code
• Tariff code
• Amount charged.

What is the process leading up to the payment of a claim?

• The membership number is verified
• The patient’s information is verified
• The claim is captured
• The claim is assessed and verified against the benefit rules
• The claim is rejected or approved for payment.

What happens if information on my claim is missing or unclear?

If information that should be on a claim is missing or unclear, we reject the claim. The “Reason code” column on your claim statement will indicate the reason for the rejection. For example, Reason code 59 means the tariff code was either incorrect or was not supplied. If the reason for not paying the claim is a lack of information, get the right information and resubmit the claim.

What do the reason and pay codes on my claims statement mean?

The reason codes tell you more about the claim that was paid; for example, that it was paid from the Chronic Medication Benefit. If the claim was not paid, the reason codes will indicate why it was not paid. It is important to read the description we provide for every reason code on your claims statement, as you may be required to submit additional information before we can pay the claim.

Can I check my claims online?

You can view your claims history online if you have internet access and are registered on the SAB Medical Aid member portal. To ensure your data remains secure at all times, claim tracking occurs in a secure, password-protected environment. Follow these simple steps to register:

• Go to www.sabmas.co.za
• Click on Register
• Follow the prompts to register a username and password.

Once you have registered, you can log in and access your information in a secure environment.

Once you are logged in, you can view your:

• Claims and monitor their status
• Membership details
• Edit your contact details

What are ICD-10 codes and why are they important?

ICD-10 codes appear on your healthcare providers’ accounts. ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems. The ICD-10 codes tell us about the condition you’re being treated for, so the Scheme can settle claims correctly. The Medical Schemes Act requires medical schemes to treat all information about members’ conditions with the utmost confidentiality. The ICD-10 codes for your diagnosis will never be shared with anyone else, including your employers or family members.

Which optometrists should I use?

Read the Optical Benefit Guide, for a detail explanation of the benefits.

The Find a Healthcare Provider tool will help you find a provider in our network.

Questions About the Specialists Network

What are the benefits of using the SAB Medical Aid Specialist Network?

This network has been established to protect you from rising healthcare costs. The Scheme has negotiated with a group of specialists to deliver quality healthcare services to you at pre-determined rates. Using these specialists for treatment both in- and out- of- hospital helps you to avoid co-payments (having to pay part of the account yourself). Partnering with these Healthcare Providers to manage costs also helps the Scheme to keep contribution increases as low as possible, while still offering you great benefits. We are constantly expanding the network so it becomes even easier and more convenient for members to receive quality healthcare at reasonable costs.

Can I use a specialist who is not in the SAB Medical Aid Specialist Network?

It’s your choice. You are free to remain under the care of a specialist who is not in our network but if your specialist charges fees higher than the Scheme Rate, you will have to pay the difference. Claims from non-network specialists that are higher than the Scheme Rate, will be paid at the Scheme Rate; you will have to settle the difference directly with the specialist. If you submit a quotation from the specialist for the planned procedure before undergoing surgery, we can tell you how much the Scheme will pay and you will be able to budget for the amount due by you.

If my treating specialist is in the network, will other providers involved in my procedure also be part of the network?

Don’t assume that if your treating specialist is in our network, other specialists involved in your procedure, such as the anaesthetist, are also part of the network. You need to confirm their network status. If they are not in the network, the Customer Care Centre can recommend alternative specialists who are part of the network. Even if your treating specialist is not in the network and you don’t want to change to a network specialist, you may still want to change to a network anaesthetist. This will reduce your out-of-pocket expenses.

What are the benefits of registering on the Chronic Care Management (CCM) Programme?

Participating in the programme will help you manage your medical condition and ensure the cost of your medicine is covered from the Scheme’s Chronic Medicine Benefit. This means you can use your Routine Insured Benefits for other medical expenses. You will also receive a treatment plan, which entitles you to a number of consultations, tests and pathology services related to your chronic condition. These are not paid from your Routine Insured Benefits, thereby stretching these benefits so you have benefits available later in the year.

How do I register on the CCM Programme?

Registration is quick and easy. Ask your doctor or pharmacist to contact our Customer Care Centre on 0860 002 133. They will speak to a consultant who will authorise your chronic medicine and register you on the programme. You can also contact our Customer Care Centre or send an email to chronic@sabmas.co.za for more information about the CCM Programme.

What are the benefits of registering on the Maternity Management Programme?

Registration ensures that you don’t miss out on the valuable benefits you are entitled to and end up paying out-of-pocket expenses unnecessarily. These benefits include:

• 12 gynaecologist or midwife consultations
• Two growth scans
• Pre-natal supplements to the value of R414 a month
• Important blood tests.

These benefits will be paid at 100% of the Scheme Rate from the Major Medical Benefit once you have registered on the programme. If you don’t register on the programme, gynaecologist consultations and the two scans will be paid from your Day-to-day Benefits.

If you want to avoid co-payments by using a gynaecologist, anaesthetist and paediatrician in the SAB Medical Aid Specialist Network, we will assist you in choosing suitable specialists based on your chosen hospital or location when you register on the programme. You will also receive a very useful pregnancy book that is full of professional advice and information.

How do I register on the Maternity Management Programme?

Registration couldn’t be easier. When you are 12 weeks pregnant, simply contact us on 0860 002 133 to register.

How do I register on the HIV Management Programme?

If a test confirms that you are HIV positive, register on the Scheme’s HIV management programme, Aid for AIDS, as soon as possible. To register, visit www.aidforaids.co.za or send a text message to 083 410 9078. You can also fax your membership number to 0800 60 07 73. All interaction with the programme will be completely confidential.

Who do I contact for emergency services?

In a medical emergency, call 082 911.

Netcare 911 is the Scheme’s provider for emergency medical services. With a fleet of over 200 emergency vehicles, Netcare 911 is able to offer great response times. Netcare 911 also offers access to free telephonic advice from registered nurses and telephonic trauma assistance by qualified trauma counsellors. Services are available 24 hours a day, seven days a week.

What benefits are covered as specialised dentistry services?

Remember to obtain a quotation prior to any treatment. Submit the quotation to info@sabmas.co.zato find out what the Scheme will cover. There is a limited benefit for this on the Comprehensive Option, but no cover on the Essential Option.

How do I contact the Scheme?

You don’t have to wait for business hours to contact us. Please send general questions to info@sabmas.co.za, questions about claims to claims@sabmas.co.za and any request for membership changes to membership@sabmas.co.za

You can also contact our customer care centre on 0860 002 133 or send a fax to 010 593 2060.