Dictionary

(Easy-to-understand explanations of medical scheme terms, jargon and abbreviations)

Acute medicine

This is medicine used for diseases or conditions that have a rapid onset, severe symptoms, and that require a short course of medicine treatment. It also refers to medicines that you can claim as benefits, but which have not been classified as chronic medicine by your scheme.

Adult

A dependant who is 21 years or older.

Adult Dependant

An adult that depends on, or interacts financially with, the main member of the scheme. An adult dependant is charged an adult contribution rate, unless otherwise stated by the scheme rules. Adult dependants are usually the husband/wife/life partner of the main member, but could also be another family member.

Agreed tariff

The cost of a service negotiated by a fund with a preferred provider, like doctors and hospitals. These providers are referred to as DSP’s (Designated Service Providers) and, if you are on such a scheme, you can only see those specific providers.

Aids

[See HIV/Aids]

Ambulance services

This includes all medically-equipped transport, including ambulances or helicopters, for a medical emergency.

Antiretrovirals

Antiretroviral drugs are medicines used in the treatment of infection by retroviruses, primarily HIV. Different classes of antiretroviral drugs act at different stages of the HIV life cycle.

[See “AZT” and “Co-trimoxazole”]

Application date

The actual date on which the scheme receives an application for membership or registration of a dependant.

AT

[See Agreed tariff]

AZT (Azidothymidine)

Azidothymidine (AZT, or ZDV, or zidovudine (INN)), is an antiretroviral drug used in the treatment of HIV. It was the first antiretroviral approved by the FDA (link to FDA).

Beneficiary

Every individual member and dependant who receives benefits from the scheme.

Benefits

The services that a member and his/her dependants qualify for when joining a medical scheme. Benefits are defined by the scheme rules. There are various types of benefits, such as Prescribed Minimum Benefits (PMBs), in-hospital benefits, day-to-day benefits, dental benefits, etc.

BHF rates (Board of Healthcare Funders)

This refers to the tariff structure that the Board of Healthcare Funders (representative of medical schemes) compiled.

[See also “NHRPL rates”]

Branded/patented medicine

Pharmaceutical companies incur high costs for research and development before a product is finally manufactured and released into the market. To recover these costs, the company is given the patent right to be the only manufacturer of the specific medicine brand for a number of years.

Cancer treatment

[See “Oncology”]

Child Dependant/Child

Someone who is a child of the principal member and who is younger than the age limit set by the scheme. In South Africa, people younger than 18 years are regarded as children. Some schemes accept people who are older than 18 years as child dependents, if they still rely on their parents. The rules of each medical scheme determines who will be accepted as a child dependant.

Chronic cover/chronic benefits

The cover that schemes provide for certain conditions in terms of its scheme rules and which must, at least, include the 26 conditions that appear on the Chronic Disease List (CDL). (Link to PMB Section)

Schemes may decide to only cover the treatment of your condition as described in a disease/treatment algorithm (i.e. explanations as to how a person should be treated) and/or a medicines list. Treatment outside of these algorithms or lists may be funded in part, or not at all. However, the law makes provision for exceptions for people who do not respond well to the treatment described in the algorithm or list. You may ask your scheme for alternative treatment or medicine and your doctor has to write a motivation.

A scheme may not charge you a higher premium solely because you have a chronic condition. Some schemes impose waiting periods for new members during which they may not cover the condition. See “waiting period”.

Chronic diseases

Illnesses or diseases requiring medicine for an uninterrupted period of more than three months. The Medical Schemes Act provides a PMB (Prescribed Minimum Benefit) listing the minimum chronic conditions your medical scheme should cover under law. With reference to this list, your medical scheme compiles its own list of approved chronic diseases that it will cover – for example high blood pressure, diabetes or high cholesterol.

[See “Chronic medicine” and “Chronic medicine benefit”]

Chronic medicine

A medicine prescribed by a medical practitioner for an uninterrupted period of at least three months. This medicine is used for a medical condition that appears on your scheme’s list of approved chronic conditions.

[See “Chronic diseases” and “Chronic medicine benefit”]

Chronic medicine benefit

A medical scheme benefit that covers medicine for a specified list of conditions. This can vary, according to the medical scheme option that you choose.

[See “Chronic diseases” and “Chronic medicine”]

Claim

After you’ve received medical treatment, you or the service provider (the doctor or hospital) submits a claim to your medical scheme to request payment of the bill. Usually you can wait for your scheme to pay out the claim, or you can pay the bill from your own pocket and then claim back the money from your scheme.

Closed (Restricted) Schemes

These schemes are only open to those employees of a particular company, profession, trade, industry, calling, association or union, which has established a scheme exclusively for its employees and members.

Commencement date

[See “Inception date”]

Consultation

This refers to your visit to your service provider, like your doctor, specialist, physiotherapist, etc.

Contribution

The fixed amount that you are paying monthly, to be a member of your medical scheme. You pay a specific amount for each adult dependant and each minor dependant that is registered under your membership.

Comprehensive Plan/Option

A plan which covers almost all medical expenses (subject to the rules of the individual scheme).  It includes benefits for in-hospital and day- to-day expenses (subject to the rules of the scheme).

Co-payment

The difference or shortfall that patients have to pay out of their own pockets to a health care practitioner or hospital that charges more for his/her services than what the scheme is prepared to pay. The conditions of co-payments are explained in the scheme’s rules. If you have a PMB/CDL condition, schemes may not require co-payments where you had no other choice and/or where immediate treatment was needed and/or where previous treatment did not work.

Co-trimoxazole

Co-trimoxazole (abbreviated SXT, TMP-SMX, or TMP-sulfa) is an antibiotic combination of trimethoprim and sulfamethoxazole used in the prophylaxis and treatment of a variety of bacterial infections, including those associated with HIV/Aids.

Cover

The word “cover” refers to the amount that the scheme will pay for treatment or care. Not all healthcare services are always covered in full (i.e. not everything will be paid for at exactly what it costs.) If your scheme says “funded in full” or “100%”, you should ask whether it is:

100% of the amount that the hospital or doctor charges,
or
100% of what the scheme regards as an appropriate rate (in which you case you would have to pay the difference, out of your own pocket.)

Day-to-day limits

You and your dependants can spend a certain maximum amount of money in a particular year for out-of-hospital expenses. These day-to-day limits can be calculated for overall expenses or expenses that fall into certain categories.

Day-to-day cover/Out-Of-Hospital Cover

Treatment that is usually delivered out of hospital and which may be of a frequent nature. It may include visits to your general practitioner, medicine for colds and flu, minor injuries etc.

[See “Threshold”]

Dental benefits

Depending on the medical scheme option you choose, you can have dental benefits, which can include a wide range of different dental treatments and procedures.

Dependant

Any person, usually a member of the family, that qualifies for cover because they depend financially on the main member. Dependants could be adult or child dependants. Schemes may charge higher premiums when more dependants are put on the scheme. Together with the principal member, dependants are also described as scheme “beneficiaries” or “members”.

Disease management

A holistic approach that focuses on the patient’s disease or condition, using all the cost elements involved. It can include patient counseling and education, behavior modification, therapeutic guidelines, incentives and penalties and case management. The beneficiary should usually co-operate with the program to be able to receive benefits.

DSP (Designated Service Provider)

Your scheme negotiated preferential rates with this specific service provider in offering you benefits for PMB (Prescribed Minimum Benefits) conditions. These are, for example, specific doctors, specialists, hospitals or pharmacies that your medical scheme wants you to use.

Effective date

[See “Inception date”]

Emergency

A medical emergency is an injury or illness that poses an immediate threat to a person's life or long-term health. These emergencies may require assistance from persons suitably qualified to help, such as paramedics, doctors and surgeons.

Exclusions

[See “Waiting period (condition specific)”]

 

Family

This is a medical scheme member and his/her dependants.

Formulary

A defined list of medicine used to treat various diseases. There are different formularies for different diseases.

Generic medicine

Generics are medicines that contain exactly the same active ingredients as their branded equivalents. The same or another company manufactures these medicines when the patent on the branded product expires. As a result, these medicines are usually much cheaper.

Herceptin

An expensive specialty chronic medicine used in some cases to treat breast cancer.

HIV/Aids

The Human Immunodeficiency Virus is a retrovirus that breaks down the human body’s immune system and can cause Acquired Immunodeficiency Syndrome (AIDS). AIDS is an incurable condition where the immune system begins to fail, leading to life-threatening opportunistic infections.

Hospital plan

A plan which covers accounts that are submitted by service providers only while you are hospitalised. You are responsible for your own day-to-day doctors’ expenses. They cost less than comprehensive medical aid plans.

Hospital Plan with Savings

A plan which covers accounts that are submitted by service providers only while you are hospitalised. You are responsible for your own day-to- day doctors’ expenses. They cost less than comprehensive medical aid plans.

ICD codes

ICD stands for “International Classification of Diseases and related problems”. Every medical condition and diagnosis has a specific ICD 10 code. These codes are used primarily to enable medical schemes to accurately identify the conditions for which you sought healthcare services. This coding system then ensures that your claims for specific illnesses are paid out of the correct benefit and that healthcare providers are appropriately reimbursed for the services they rendered. The inclusion of ICD 10 codes on claims from healthcare providers to medical schemes is a mandatory requirement since 1 January 2005.

Inception date

This is the date on which you become a member of a scheme and your dependants’ membership is registered. Your premiums are payable from this date.

What is a late joiner penalty?

It is a penalty by way of additional contributions, imposed on persons joining a scheme late in life i.e. an applicant who is 35 years of age or older who was not a member of one or more medical schemes as from a date preceding 01 April 2001 without a break in coverage exceeding three consecutive months since 01 April 2001.

Major medical benefits

All the benefits for services you are insured for, like hospitalisation, procedures and treatment you can receive while in hospital.

Managed healthcare

This is any effort to promote the rational, cost-effective and appropriate use of healthcare resources. Usually members only qualify for benefits if they have followed the guidelines and protocols the medical scheme has set out to manage the illness.

Example: In the case of oncology treatment, managed healthcare would probably mean that you’d have to join a case management programme. Your doctors and specialists and the specialists from your medical scheme will work together to decide on the most cost-effective treatment programme as a team.

Member

Any person who has been registered as a member by a scheme – including main members and dependants.

Minor/Child Dependant

A dependant who is not yet 21 years old. Some schemes also include older students as “minors”.

MSA (Medical Savings Account)

The medical savings plan is designed to cover day-to-day expenses. The consumer contributes a fixed monthly amount into a savings account. The total annual amount available in the savings account is available in advance for medical expenses.
In terms of the medical schemes regulations, the amount may not be more than 25% of his premium for the year. Once the benefit has been used up, the consumer is responsible for the day-to-day expenses. Any positive balance in the savings account at the end of the year is carried over to the next year.

Network/Capitation Option

This plan provides individuals with basic day-to- day cover at affordable prices, at specific network providers.  Network Providers differ from scheme to scheme. A general limit is placed on the cost of the services, treatment
or medication to be obtained as part of that benefit. It means that your scheme pays the service provider (doctor, hospital or pharmacy) a set fee, and they have to ensure that you are treated within the limit of that set fee.

Members have to use designated service providers / network doctors.
(See Network and DSP)

NHRPL (National Health Reference Price List)

The Department of Health publishes these tariffs and rules for specific health services or supplies. Medical schemes are obliged to follow these rules and tariffs.

Non-prescribed medicine

[See “Pharmacist Advised Therapy (PAT)”]

Oncology

Oncology is the field of healthcare that deals with the treatment of cancer. Oncology benefits refer to the cover that schemes are prepared to pay for cancer treatments. Not all types of cancer, and not all stages of cancer, form part of the PMBs. Different scheme options offer different cover for different types of cancer treatments.

Open Schemes

These schemes are open to the public. There are currently 34 open medical schemes in South Africa. They are characterised by more innovative benefits, as they have to compete for new members.  They also have higher administrative and marketing costs.

Optical benefits

Depending on the medical scheme option you choose, you can have optical benefits, which can include a wide range of optical treatments and supplies, like eye examinations, spectacles and contact lenses.

Options

These are the different products registered by medical schemes, offering members sets of specific benefits.

PMB (Prescribed Minimum Benefits)

Prescribed Minimum Benefits refer to the conditions that schemes are obliged to fund for all its members, in full and without co-payment. The PMB list contains about 270 conditions and treatments (go to www.medicalschemes.com for the complete list).

The aim of PMBs is to provide every person on a medical scheme with at least a minimum set of benefits and to prevent members from running out of benefits for these conditions. If the required PMB treatment goes beyond what is described on the list, the scheme may decline to fund that treatment. Always ask your doctor, pharmacist or hospital whether the treatment you will be receiving is part of the PMBs or not. (Link to PMB Section)

Pre-authorisation

The process of getting approval before any planned admission to a hospital. Your scheme will supply you with prior approval in the form of a pre-authorisation number.

Primary Healthcare Provider

A primary healthcare provider deals with you and your family’s day-to-day healthcare needs – like treating a minor burn. These can include general practitioners (GP’s) and nurses.

Private hospital

Unlike state hospitals, private hospital groups are run as businesses and cost a whole lot more. Although some state facilities are excellent, private hospitals usually offer more luxury and better aftercare. If you’re a member of a medical scheme, you will probably receive healthcare in a private hospital.

Pro-rata benefits

Some of your medical scheme benefits are given on a calendar year basis, which means that you have an annual limit on them. If you join a scheme on a date other than 1 January, your benefits are calculated pro-rata, which means that you receive a year’s benefits in advance. If you exceed your annual limit, you’ll have to pay excess costs out of your own pocket.

Provider network/Preferred providers

A healthcare provider or group of healthcare providers identified by a medical scheme as the preferred provider or providers to treat and care for its members in respect of one or more specific benefits.

For example, you can only go to a particular hospital group or all medicine should be obtained through a medicine courier company. Should you freely choose to go to a hospital outside of the group, or get your medicines from another pharmacy, the scheme may ask you to make a co-payment.

Risk

In some cases, your monthly contributions to your medical scheme will be split into two portions – a risk and a savings portion. The risk portion reflects your contribution to benefits that are being paid by the scheme and not from a savings component.

Risk underwriting

When a scheme looks at the application of a group, they will require certain information from the company in order to see what the risk to the scheme will be. Risk factors include the average age of the employees, the pensioner ratio, as well as the number of chronic medicine users within the group. Once this information has been established, the scheme can decide what underwriting will be applied to the group with regards to new applicants.

Self-payment gap

When your scheme benefits or medical savings account is used up, there will be a period during which you will have to fund a certain portion of your claims from your own pocket.

Service date

This can be the date on which you are discharged from hospital, the date you have received a medical service or medical supplies, or the date you terminate your membership.

Service provider

Anyone who gives you medical advice and service, like your doctor, dentist, pharmacist, nurse, medical auxiliary or hospital.

Specialist

For specialized medical treatment that cannot be offered by your general practitioner (GP), you can receive care from a wide range of specialists, including internists, cardiologists, urologists, gynaecologists, pathologists, a wide range of surgeons and, in the case of an operation, anaesthetists.

Spouse

The person you are married to under any law or custom that is recognised by South African law.

Start date

[See “Inception date”]

State hospital

The system of hospitals of each provincial government in South Africa. These can include training hospitals where nurses, doctors, specialists and other medical professionals are trained. If your local state hospital does not offer specialist treatment of a disease, your state health service provides any necessary transfer to other state hospitals outside your province of residence where you can get the necessary treatment.

TB

[See Tuberculosis]

The Bill

The Medical Schemes Act of 1998. This act stipulates your rights as a medical scheme member. The Bill and the regulations thereunder are amended or replaced from time to time.

Threshold

On some medical scheme options, you pay for your day-to-day medical expenses from your medical savings account. Once this is finished, you will have to pay from your own pocket (self payment gap), until your claims reach a certain level (threshold).  Once your day-to-day expenses have reached that fixed rand amount, for example, R5 000, (your “threshold”), your medical scheme kicks in and will pay further claims, up to a certain limit.

Tuberculosis

Tuberculosis (abbreviated as TB for Tubercle Bacillus) is a common and treatable deadly infectious disease, especially prevalent in HIV/Aids patients. It most commonly affects the lungs, but can also affect the central nervous system, the lymphatic system, the circulatory system, the genitourinary system, bones, joints and even the skin.

Underwriting

Depending on your previous medical scheme history, your new medical scheme can apply underwriting on your new membership. This means that, according to regulation, they are allowed to impose a three-month general waiting period and/or a twelve-month waiting period on an existing illness condition. A Late Joiner Penalty can also be placed.

[See “Waiting period (condition specific)”, “Waiting period (general)” and “Late joiner”]

Waiting period (condition-specific)

Depending on your previous medical scheme history, a scheme may impose a waiting period of up to 12 months from the inception date of your membership, for any pre-existing conditions. No benefits will be paid out for any costs relating to this condition.

Waiting period (general)

Your scheme will probably have a three-month general waiting period on benefits for new members. No benefits are paid out during this period, not even from an MSA (medical savings account), except for some procedures that are covered within the PMB (Prescribed Minimum Benefit) as prescribed by the Medical Schemes Act.

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