Frequently Asked Questions

You can add eligible family members who rely on you for financial support, including:

Adding eligible dependants gives them access to SABMAS healthcare cover.

For full membership and dependant eligibility rules, please refer to the Scheme Rules.

• Your spouse or life partner
• Your children or stepchildren
• Children in your legal care or custody
• Dependent grandchildren
• Adult children who are full-time students and still financially dependent on you
• Adult children with a disability who are financially dependent on you
• Financially dependent parents or parents-in-law who meet the Scheme's dependency requirements

If you get divorced or end a domestic partnership, your former spouse or partner can no longer remain registered as a dependant on your SABMAS membership.

To avoid any issues with claims and contributions, please let us know as soon as you can when your relationship status changes. This will allow us to update your membership details and remove your former spouse or partner from your cover.

If claims are paid on behalf of a former dependant after they are no longer eligible, you may be required to repay those costs to the Scheme.

Please contact your People Department for help with removing a dependant and updating your membership information.

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 should include an affidavit indicating that the dependant is not permanently employed and is dependent on the principal member for family care and support, or for a full-time student, proof of registration from the institution where they are registered.

For a dependant with a disability, a medical report confirming the nature of disability must be submitted in addition to the affidavit.

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.

All dependants who are 21 years and older are charged at adult dependant rates, except for children with disabilities, who are charged child dependant rates until they turn 26.

Your dependant may continue to remain on your membership if they are:

• a full-time student, or
• not permanently employed and remain financially dependent on you.

To confirm their eligibility, you must provide updated proof every year, such as:

• Proof of registration from their educational institution, or
• An affidavit confirming that they are not permanently employed and that they are dependent on you for family care and support.

If the required proof is not provided, your dependant will no longer qualify for cover and will be removed from your membership.

Submitting your documents on time helps make sure your dependant's healthcare cover continues without interruption.

Yes, in some cases.

A late joiner penalty is an additional amount that may be added to your monthly contribution if you join a medical scheme for the first time or rejoin after spending a number of years without medical scheme cover, and you are 35 years or older.

These penalties are allowed under the Medical Schemes Act and help ensure fairness for all members. They discourage people from joining a medical scheme only when they need expensive medical treatment, while long-term members have been contributing continuously over the years.

Who may be affected?

A late joiner penalty may apply if:

• You are 35 years or older, and
• You have had a gap in medical scheme membership or have never belonged to a medical scheme before.

Yes, in some cases.

If you are 35 years or older and have had a period without South African medical scheme cover, a late joiner penalty may apply when you join SABMAS.

The penalty is calculated as a percentage of the risk portion of your monthly contribution. It does not apply to the savings portion of your contribution (where applicable).

The calculation is based on your age and the number of years you were not covered by a South African medical scheme after the age of 35.

Calculation:

Current age − (35 + years of creditable cover) = Years without cover

Creditable cover refers to membership of a registered South African medical scheme after the age of 21. It does not include:

• Cover provided by foreign medical schemes
• Medical scheme membership as a dependant before the age of 21

Maximum penalties

Depending on the number of years without cover, the following maximum penalties may apply:

• 1 to 4 years without cover: Up to 5%
• 5 to 14 years without cover: Up to 25%
• 15 to 24 years without cover: Up to 50%
• 25 years or more without cover: Up to 75%

The actual penalty applied is determined according to legislative guidelines and Scheme Rules.

Example

Thabo is 48 years old and was a member of a South African medical scheme for 10 years after turning 21. He then spent 17 years without South African medical scheme cover before joining SABMAS.

His late joiner assessment would be calculated as follows:

48 − (35 + 10) = 3 years without cover

Based on the guidelines, 3 years without cover falls into the 1 to 4 years category, which may result in a late joiner penalty of up to 5% of the risk portion of his monthly contribution

Medical Savings Account (MSA) contributions are available only to members on the Comprehensive Option.

A portion of your monthly contribution is set aside for you in a Medical Savings Account, which can be used for eligible day-to-day healthcare expenses, such as co-payments, member portions, and certain healthcare costs not covered by your benefits.

How it works

Each year, an amount equal to 10% of your total annual contribution (including contributions for your dependants) is allocated to your Medical Savings Account.

To help you manage your healthcare expenses throughout the year, this amount is paid into your MSA quarterly:

• 1 January
• 1 April
• 1 July
• 1 October

Example

If your annual Medical Savings Account allocation is R1 200, your funds will be added as follows:

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

Prescribed Minimum Benefits (PMBs) are a set of healthcare benefits that all South African medical schemes are legally required to provide.

PMBs make sure that members receive cover for the diagnosis, treatment, and care of certain medical conditions, regardless of the benefit option they have selected.

These conditions include a range of serious, life-threatening, and chronic illnesses, helping to make sure that members have access to essential healthcare when they need it most.

What this means for you

As a SABMAS member, you are entitled to PMB cover for qualifying conditions, provided the Scheme's Rules and clinical requirements are met.

To receive full PMB benefits, you may be required to:

• Register certain conditions with SABMAS
• Follow approved treatment plans and clinical protocols
• Use a designated service provider where applicable

Why PMBs are important

PMBs help protect you from unexpected healthcare costs by ensuring that essential treatment for qualifying conditions is covered, giving you confidence when facing serious health challenges.

Network healthcare professionals play an important role in helping you access quality healthcare while making the most of your SABMAS benefits.

A network healthcare professional is for example a general practioner (GP) or specialist that has an agreement with SABMAS to provide healthcare services to members at contracted rates.

How network healthcare professionals help you

When you use a network healthcare professional, you can:

• Access quality healthcare from approved healthcare professionals
• Receive treatment that meets recognised clinical standards
• Reduce or avoid from your own pocket medical expenses
• Make the most of your available benefits
• Receive coordinated care for ongoing medical conditions

Designated service providers and Prescribed Minimum Benefits (PMBs)

For members receiving treatment for a Prescribed Minimum Benefit (PMB) condition, designated service providers are the Scheme's preferred healthcare professionals for diagnosis, treatment, and ongoing care.

This helps make sure that:

• You receive the appropriate treatment for your condition
• Care is provided according to approved clinical guidelines
• Healthcare costs are managed responsibly, helping to protect the sustainability of the Scheme for all members

What this means for you

Using a network healthcare professional when required can help ensure your treatment is covered according to the Scheme's rules and benefit structure. If you choose to use a healthcare professional outside the network, you may be responsible for certain costs unless exceptions apply.

Find a network healthcare professional

If you are unsure which healthcare professionals form part of the network, select this link to use our Find a healthcare professional tool.

To help us process your claim quickly and accurately, please make sure the following information is included when you or your healthcare professional submits a claim:

A network healthcare professional is for example a general practioner (GP) or specialist that has an agreement with SABMAS to provide healthcare services to members at contracted rates.

• Patient's full name
• ID number or date of birth
• Membership number
• Doctor's practice number
• Date of treatment or service
• ICD-10 (diagnosis) code
• Tariff code(s) for the treatment or service provided
• Amount charged
• Proof of payment (if you have paid the claim yourself)

Your claims statement includes reason codes to help you understand how your claim was processed.

Reason codes

Reason codes provide additional information about your claim, including:

• Why a claim was paid
• How your claim was assessed
• Which benefit was used to pay the claim
• Why a claim was not paid in full or was rejected
• Whether there is an outstanding amount
• If any additional information is needed

For example, if a claim was not paid, the reason code description will explain why and may indicate what action you need to take, such as submitting supporting documents or updating information.

Yes. As a SABMAS member, you can view and track your claims online.

The portal gives you secure, convenient access to your healthcare information anytime and anywhere you have internet access.

How to register

Registering is simple:

1. Visit www.sabmas.co.za
2. Select Register
3. Follow the prompts to create your username and password

To protect your personal information, the member portal is a secure, password-protected platform.

What can you do on the SABMAS website?

Once you have registered and logged in, you can:

• View your claims history
• Track the status of your claims
• Access your membership details
• Update your contact information

ICD-10 codes are internationally recognised diagnosis codes used by healthcare professionals to identify the medical condition, illness, or injury for which you are receiving treatment.

These codes appear on accounts and claims submitted by your doctor, specialist, hospital, or other healthcare professionals..

Why are ICD-10 codes important?

ICD-10 codes help us to:

• Understand the condition being treated
• Assess and process claims accurately
• Determine which benefits apply to your treatment
• Ensure claims are paid correctly according to Scheme Rules and healthcare regulations

Providing the correct ICD-10 code helps avoid delays in processing your claims and ensures you receive the benefits you are entitled to.

How is your information protected?

Your health information is treated with the highest level of confidentiality.

In line with the Medical Schemes Act, SABMAS protects all information related to your medical condition and diagnosis. Your ICD-10 codes and related health information will not be shared with anyone who is not authorised to access them, including employers, colleagues, or family members.

What this means for you

ICD-10 codes help SABMAS process your claims correctly while ensuring your personal health information remains private and secure. This means you can have confidence knowing that your medical information is handled confidentially and with care.

Getting pre-authorisation before a planned hospital admission is an important step that helps you make the most of your SABMAS benefits and avoid unexpected costs.

The process helps make sure that you receive the right treatment for your condition while helping to manage healthcare costs.

How pre-authorisation helps you

Pre-authorisation helps you::

1. Confirm whether your planned procedure or treatment is covered by your benefits
2. Understand what benefits are available for your hospital stay
3. Ensure that the proposed treatment is appropriate for your medical condition

Avoid unexpected costs

By obtaining pre-authorisation before your admission, you will have a clearer understanding of what SABMAS will cover and whether there may be any costs for which you are responsible.

Plan with confidence

Pre-authorisation gives you the information you need to make informed healthcare decisions, helping you prepare for your treatment and focus on your recovery with greater confidence.

Obtaining pre-authorisation is a simple process that helps ensure your admission is covered and that you understand your available benefits before treatment takes place.

Step 1: Gather the required information

Before contacting SABMAS, confirm the following details with your doctor or specialist:

1. The date and time of the procedure or treatment
2. The hospital where you will be admitted, including their practice number
3. The doctor or specialist's practice number
4. The tariff code(s) for the procedure
5. The relevant ICD-10 diagnosis code(s)

If you are unsure where to get this information, your treating doctor's rooms will be able to help you.

Step 2: Contact SABMAS

Once you have all the required information, call our Customer Care Centre on 0860 002 133 and follow the voice prompts to connect with the appropriate consultant.

Step 3: Discuss your admission and benefits

A SABMAS customer care consultant will:

• Capture your admission details
• Confirm your available benefits
• Explain any requirements related to your admission

Plan ahead for peace of mind

By obtaining pre-authorisation before your planned admission, you can better understand your cover, make informed decisions about your treatment, and avoid unexpected costs.

We understand that emergencies are unexpected and often stressful. In these situations, your focus should be on getting the medical care you need as quickly as possible.

How to obtain authorisation for an emergency admission

For an emergency hospital admission, either you, a family member, or the hospital should contact our Customer Care Centre on 0860 002 133.

Our business hours are Monday to Friday, 07:00 to 17:00. If you are unable to contact us during business hours because of the emergency, you have 48 hours from the first business day after the admission to obtain authorisation.

Obtaining the required authorisation helps make sure that your claims are processed and paid correctly.

How will your hospital costs be covered?

• Prescribed Minimum Benefit (PMB) conditions, such as a heart attack or stroke, will be covered according to PMB rules.
• Claims that do not qualify as PMBs will be covered according to your available benefits and the applicable Scheme Rates.

Step 3: Discuss your admission and benefits

A SABMAS customer care consultant will:

• Capture your admission details
• Confirm your available benefits
• Explain any requirements related to your admission

Plan ahead for peace of mind

By obtaining pre-authorisation before your planned admission, you can better understand your cover, make informed decisions about your treatment, and avoid unexpected costs.

To get the most value from your optical benefits, we recommend visiting an optometrist in the SABMAS Optometry Network.

Network optometrists have been selected to provide quality eye care and services at agreed rates, helping you make the most of your available benefits and reducing the risk of from your own pocket expenses.

How to find a network optometrist

Finding a healthcare professional near you is quick and easy.

Use the Find a Healthcare Professional tool to search for a participating optometrist in your area..

The SABMAS Specialist Network is designed to help you access quality specialist care while keeping your healthcare costs as low as possible.

SABMAS has partnered with a network of specialists who provide healthcare services at agreed rates, helping you get the treatment you need while making the most of your benefits.

How the Specialist Network helps you

When you use a specialist in the SABMAS network, you can:

• Access quality healthcare from approved specialists
• Reduce or avoid co-payments and unexpected medical expenses.
• Make the most of your available benefits
• Receive specialist care at negotiated rates
• Enjoy greater confidence when planning treatment

Specialist referrals

To prevent additional co-payments, you need to get a referral from your GP.

Helping to keep healthcare affordable

By partnering with network specialists, SABMAS can better manage healthcare costs for all members. This helps the Scheme continue to offer valuable benefits while keeping contribution increases as low as possible.

Growing for your convenience

We are continually expanding our Specialist Network to make it easier for you to find a participating specialist close to where you live or work.

Find a network specialist

Using a network specialist is one of the best ways to maximise your benefits and minimise from your own pocket costs. Use the Find a Healthcare Professional tool to locate a participating specialist in your area.

Yes. You are free to choose the specialist you would like to see, including specialists who are not part of the SABMAS Specialist Network. However, it's important to understand how this may affect your costs.

What happens if you use a non-network specialist?

SABMAS will pay approved claims from non-network specialists at the Scheme Rate, you will be responsible for paying the difference (co-payment) directly to the specialist. This may result in out-of-pocket costs.

If your specialist charges more than the Scheme Rate, you will be responsible for paying the difference directly to the specialist. This amount is often referred to as a shortfall.

How can you avoid unexpected costs?

Before undergoing a planned procedure or surgery, ask your specialist for a quotation and submit it to SABMAS for review.

This allows us to:

• Confirm how much the Scheme will pay
• Identify any potential shortfalls
• Help you understand your expected from your own pocket costs
• Give you the opportunity to budget and plan ahead

Why consider a network specialist?

Using a specialist in the SABMAS Specialist Network can help you:

• Reduce or avoid co-payments
• Access quality care at negotiated rates
• Make the most of your available benefits
• Minimise unexpected healthcare expenses

Making an informed choice

The choice is always yours. Whether you use a network or non-network specialist, understanding your benefits and potential costs beforehand can help you make informed decisions and avoid surprises when your claim is processed.

Not necessarily. Even if your treating specialist is part of the SABMAS Specialist Network, other healthcare professionals involved in your procedure, such as the anaesthetist, assistant surgeon, or other specialists, may not be.

Why is this important?

If one of the providers involved in your treatment is not part of the network and charges more than the Scheme Rate, you may be responsible for paying the difference yourself.

Checking network participation before your procedure can help you avoid unexpected from your own pocket expenses.

What should you do?

Before your planned procedure:

This allows us to:

• Ask for the names of all healthcare professionals involved in your treatment.
• Confirm whether each healthcare professional is part of the SABMAS Specialist Network.
• Contact the SABMAS Customer Care Centre if you need help verifying a healthcare professional's network status.

Can you use alternative providers?

Yes. If a healthcare professional, such as an anaesthetist, is not part of the network, the Customer Care Centre can provide the details of network healthcare professionals where available.

Registering for the Chronic Benefit can help you manage your chronic condition more effectively while making the most of your SABMAS benefits.

How the Chronic Benefit helps you

When your chronic condition is approved and registered, the cost of your approved chronic medicine is covered through the Chronic Benefit, subject to Scheme Rules.

This means your day-to-day benefits can be preserved for other day-to-day healthcare expenses.

Additional support for managing your condition

As part of the programme, you'll receive a treatment plan that may include cover for healthcare services related to your chronic condition, such as:

• Doctor consultations
• Pathology tests
• Monitoring and follow-up care
• Other approved healthcare services linked to your condition

These services are covered through the Chronic Benefit and are not paid from your day-to-day benefits, helping your day-to-day benefits last longer throughout the year.

Why register for the chronic benefit?

Registering can help you:

• Access cover for approved chronic medicine
• Better manage your long-term health condition
• Preserve your day-to-day benefits for other healthcare needs
• Receive appropriate monitoring and support through an approved treatment plan
• Get more value from your SABMAS membership

Registering for the Chronic Benefit is simple and can help you access cover for approved chronic medicine and related healthcare services.

How to register

You can register in any of the following ways:

• Ask your doctor to contact the SABMAS Customer Care Centre on 0860 002 133
• Ask your pharmacist to contact the Customer Care Centre on your behalf
• Contact the Customer Care Centre yourself for help
• Email chronic@sabmas.co.za for more information

What happens next?

A MediKredit consultant will:

• Review the information provided
• Authorise approved chronic medicine, where applicable
• Register you on the Chronic Benefit
• Explain any additional requirements or benefits available to you

Need help?

If you have questions about your condition, medicine cover, or the registration process, contact the SABMAS Customer Care Centre on 0860 002 133 or email chronic@sabmas.co.za.

Registering for the Maternity helps you make the most from your benefits throughout your pregnancy and can reduce the risk of unexpected from your own pocket expenses.

By registering early, you'll have access to a range of maternity benefits and support designed to help you and your baby stay healthy.

Benefits available once you register

You may qualify for:

• Gynaecologists

Using network specialists can help reduce or avoid co-payments and make the most of your available benefits.

Additional support for your pregnancy journey

As part of the programme, you will also receive a helpful pregnancy guide packed with professional advice, practical tips, and useful information to support you throughout your pregnancy.

Registering for the Maternity Benefit is simple and takes just a few minutes.

When should you register?

As soon as you are confirmed as being pregnant, contact SABMAS to register for the programme and start accessing your maternity benefits.

How to register

Call the SABMAS Customer Care Centre on 0860 002 133. A consultant will help you with the registration process and explain the maternity benefits and support available to you throughout your pregnancy.

Why register early?

Why register early?

• Access your available maternity benefits
• Make the most of your cover and reduce potential from your own pocket costs
• Receive guidance on network specialists
• Get the support and information you need for a healthy pregnancy journey

We are here to support you

The Maternity Management Programme is designed to support you every step of the way, helping you access the care, benefits, and resources you and your baby need.

If you have tested positive for HIV, it is important to register for the HIV Management Programme with Aid for Aids as soon as you can. Early registration helps you access the support, treatment, and benefits available to help you manage your health.

How to register

You can register in any of the following ways:

• Visit www.aidforaids.co.za
• Contact 0860 100 646
• Send an SMS to 083 410 9078
• Fax your SABMAS membership number to 0800 60 07 73

Why register?

Registering for the programme can help you:

• Access approved HIV treatment and medicine
• Receive ongoing clinical support and care
• Better manage your long-term health
• Make the most of your available healthcare benefits

Your privacy matters

All interactions with the HIV Management Programme are handled with the strictest confidentiality. Your personal and medical information is protected and will only be accessed by authorised healthcare professionals involved in your care.

We're here to support you

The HIV Management Programme is designed to provide the care, support, and guidance you need to manage your health with confidence and peace of mind.

If you or a family member needs urgent medical help, contact Netcare 911 on 082 911.

SABMAS partners with Netcare 911 to provide emergency medical services 24 hours a day, 7 days a week.

How can Netcare 911 help you?:

Netcare 911 offers:

• Emergency medical response services
• Access to a large fleet of emergency vehicles across South Africa
• 24/7 telephonic medical advice from registered nurses
• Telephonic trauma counselling and support from qualified trauma counsellors

Available at any time

Whether you need emergency medical assistance, urgent healthcare advice, or emotional support following a traumatic event, Netcare 911 is available around the clock to help you.

We are here to help and you can contact us in the way that's most convenient for you.

You do not have to wait for business hours to send us an email. Simply contact the relevant team below, and we will help you with your query.

Email us:

• General questions: info@sabmas.co.za
• Claims questions: claims@sabmas.co.za
• Membership changes and updates: membership@sabmas.co.za

Contact us

Customer Care Centre: 0860 002 133

We are here to help

Whether you have questions about your benefits, claims, membership, or healthcare cover, our team is ready to help you and help you get the most from your membership.