This is a medical scheme member and his/her dependants.
A defined list of medicine used to treat various diseases. There are different formularies for different diseases.
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.
An expensive specialty chronic medicine used in some cases to treat breast cancer.
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.
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 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.
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.
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.
Any person who has been registered as a member by a scheme – including main members and dependants.
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.
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.
[See “Pharmacist Advised Therapy (PAT)”]
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.
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.
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.
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)
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.
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.
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.
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.
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.
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.
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.
Anyone who gives you medical advice and service, like your doctor, dentist, pharmacist, nurse, medical auxiliary or hospital.
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.
The person you are married to under any law or custom that is recognised by South African law.
[See “Inception date”]
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.
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.
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 (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.
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.