Managed Care Programmes and Chronic Benefits

As part of our aim of identifying and managing beneficiaries’ disease risks in good time, there are a number of programmes that form part of our Managed Care approach. Certain chronic conditions are also covered across all plans.

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Managed Care Programmes

This section outlines the details of the six programmes that form the core of OMSMAF’s Managed Care offering. (These benefits may differ across Plans.) Visit our Contact Us page for contact details.

Back and Neck Rehabilitation Programme

The successful management of back and neck pain via the Fund’s conservative back and neck programme will improve your quality of life and reduce your pain and suffering.

The programme is based on internationally successful care pathways that reduces pain and stiffness and improve flexibility. It is also proven to limit, avoid or postpone surgery. Where surgery is truly warranted, this will be permitted within Fund rules.

To ensure that all eligible members are enrolled, there are a number of ways to access the programme:

  • The telephonic helpline on 0860 100 076.
  • Identification through predictive modelling.
  • Intervention prior to pre-authorisation of back and neck surgery.
  • For employees, your line manager may refer you to Universal Healthcare to assess your eligibility for one of the programmes.
  • Referral from your family practitioner or specialist.

Oncology Benefit Management Programme for cancer patients

If you are diagnosed with cancer, the Oncology Benefit Management Programme will not only help you to manage your Oncology Benefits in relation to the high costs associated with treatment, but you will also receive support and education on your condition.

By joining the Programme when you are diagnosed with cancer, you will qualify for the Oncology Benefit. This benefit forms part of your Hospital Benefits, subject to the Oncology sub-limit.

If you are diagnosed with cancer, your treating Oncologist must submit a proposed Care Plan for pre-authorisation before your treatment can begin. This Care Plan should provide information such as the date of diagnosis, ICD-10 code, the area to be treated, any prior surgery or treatment plus history, new treatment requested, as well as approximate costs.

The Care Plan must be submitted to Oncology Benefit Management by sending a fax to 0864 613 917 or an email to oncology@omsmaf.co.za.

HIV and AIDS
Management Programme

OMSMAF has a benefit in place specifically for HIV/AIDS related medicines and tests. This benefit is used to pay for medicines to suppress the virus and medicines to protect against illnesses such as TB and serious pneumonia and regular monitoring tests. The Fund will also pay for one HIV test per beneficiary per year.

If a test shows you are HIV positive you must register with the HIV/AIDS Management Programme as soon as possible to make use of this benefit.

Telephone them in confidence on 0860 378 800, follow the prompts for HIV Disease Management and ask for an application form.

Your doctor can also contact the HIV/AIDS Management Programme on your behalf and may also contact the medical team for advice.

Mental Health Programme

Our Mental Health Programme has been built around the principle of providing support to both you and your family practitioner to promote access to the best quality primary mental healthcare that is available.

The Mental Health Programme can support you with mental health conditions or substance-abuse issues that you may have, such as Depression, General Anxiety, Bipolar Mood Disorder or Post-Traumatic Stress Disorder.

There are a number of ways to access the programme:

  • The telephonic helpline on 0860 100 076.
    Identification through predictive modelling.
  • Intervention prior to pre-authorisation of back and neck surgery.
  • For employees, your line manager may refer you to Universal Healthcare to assess your eligibility for one of the programmes.
  • Referral from your family practitioner or specialist.

Active Disease Risk Management Programme

A co-ordinated system of health care interventions aimed at supporting members with chronic diseases with the emphasis on preventing exacerbation and/or complications utilising evidence based protocols, formularies and care plans.

The service applies to beneficiaries with the following chronic conditions:

  • Asthma.
  • Cardiovascular Disease i.e. Cardiac Failure,
  • Coronary Artery Disease.
  • Chronic Obstructive Pulmonary Disease.
  • Chronic Renal Disease.
  • Diabetes Mellitus Type 1 and 2.
  • Hypertension.
  • Hyperlipidaemia.
  • Mental Health: Depression, General Anxiety, Bipolar Mood Disorder, Post-Traumatic Stress Disorder (PTSD) and Substance Abuse.

Contact details for the Active Disease Risk Management Programme:

  • Tel: 0860 100 076
  • Email: diseasemanagement@omsmaf.co.za

Mother and Baby Care Programme

This Programme is available to members and their dependants during their pregnancy, the birth and after the birth.

The following services are covered:

  • 100% of the SPNP rate for midwives (for midwife delivery or home delivery).
  • Education and support services.
  • Care after the birth services, e.g. home visits by a registered nurse and phototherapy treatment for your baby at home, if required, subject to managed healthcare protocols and pre-authorisation.
  • A Doula (birthing coach) on all the options as part of the in-hospital maternity benefits, subject to a limit of R2 730 per pregnancy, specifically for the confinement (delivery).
  • No post-natal follow-ups.

Contact details for the Mother and Baby Care Programme:

  • Telephone: 0860 100 076 (Follow the voice prompts.)
  • Fax: 0862 957 355
  • Email: maternity@omsmaf.co.za

Chronic Benefits

What is a chronic condition?
A chronic condition is a condition that requires on-going long-term or continuous medical treatment. Contact 0860 100 076 if you are an OMSMAF member or 0860 100 076 (doctors & pharmacists) to check if a particular chronic condition is covered. Alternatively, you can email chronic@omsmaf.co.za.

All five Plans have an unlimited chronic medicine benefit for Prescribed Minimum Benefits (PMB) conditions specified in the Government Gazette by the Minister of Health.

In addition, you qualify for certain non-PMB (Prescribed Minimum Benefit) chronic conditions, depending on the Plan you have selected.

All medicine claims are paid at 100% of the actual medicine price or the Maximum Medical Aid Price (MMAP), whichever is the lesser.

MMAP is a reference pricing system that uses a benchmark or reference price for generically similar products. The MMAP is updated regularly and there may be a change to the amount your Fund will pay for your medicine. Check in with your pharmacist regularly to keep up to date with the MMAP changes.

Chronic Medicine Formularies

A Formulary is a list of cost effective evidence-based medicines that the Fund will cover for the treatment of your chronic condition. These lists are compiled by the Universal Healthcare Chronic Medicine Programme and are constantly reviewed.

Reimbursement is subject to the following Universal Healthcare Chronic Medicine Programme clinical guidelines and protocols, and the Maximum Medical Aid Price (MMAP). The Fund applies an Universal Healthcare Restrictive Formulary and Comprehensive Formulary as part of the guidelines.

The Universal Healthcare Restrictive Formulary, applicable to the Hospital and Savings Plans, contains a list of medicines that provide cover for the listed chronic conditions.

The Universal Healthcare Comprehensive Formulary, applicable to the Traditional and Traditional Plus (including SELECT) Plans, provides access to a wider range of medicines than the Universal Healthcare Restrictive Formulary.

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