4.13 Late Joiner Penalties
The Medical Schemes Act provides that a medical scheme may apply premium penalties to an applicant or dependent of a late joiner and such penalties must be applied only to the portion of the contribution related to the member or any adult dependent who qualifies for late joiner penalties. A late joiner means an applicant […]
4.12 Threshold Limits
Some medical scheme plans have a day-to-day benefit made up of a savings account followed by a self-payment gap until a pre-determined threshold is reached. Once the threshold is reached, the scheme will start paying for day-to-day claims again. Some plans have unlimited above threshold limits, which essentially means that once you have paid the self-payment […]
4.11 Limits
Every scheme’s hospital plans and medical aid plans will have unique levels of cover – and unique medical hospital cover limits. The limits can either be specified per event, per member or per family.
4.10 Medicine Formulary
A medical scheme may draw up what is known as a formulary – a list of safe and effective medicines that can be prescribed to treat certain conditions. The scheme may state in its rules that it will only cover medication in full if your doctor prescribes a drug on that formulary.
4.9 Prescribed Minimum Benefits
A familiarity with the prescribed minimum benefits is necessary to advise clients with regards to their entitlement to benefits in the medical scheme and specific option for which they are a member. The Council for Medical Schemes introduced the PMB in 2000 to define the minimum levels of cover. These minimum benefits are a safety […]
4.8 Co-Payments
A medical scheme may provide in its rules that a member is required to pay a charge to the provider for certain health care services received. The co-payment can be a fixed rand amount or a percentage of the cost.
4.7 Tariffs as benefits
The medical scheme in its rules clearly states what the medical scheme rates for different disciplines of service providers will be. Medical expenses in South Africa are not regulated. Health professionals and hospitals can charge what they want, provided that the fees are deemed fair value to the client. However, guidelines have been issued. There […]
4.6 National Health Reference Price List
The National Health Reference Price List (NHRPL) is a list of procedure codes with tariffs linked to it. These tariffs are annually revised and published by the National Department of Health. The NHRPL is intended to serve as a baseline against which medical schemes can individually determine benefit levels and health service providers can individually […]
4.5 Procedure codes
Procedure codes are numeric or alphanumeric codes that are used to identify medical services, treatment and procedures performed by health care professionals. Every claim must have a procedure code linked to a tariff. In South Africa the procedure codes used are listed in the National Health Reference Price List (NHRPL).
4.4 ICD 10 Codes
ICD 10 stands for International Classification of Diseases and Related Health Problems (10th revision). It is a coding system developed by the World Health Organisation (WHO) and translates the written description of medical and health information into standard codes. These codes are used to inform medical schemes of the conditions for which members sought health […]