Patient zone
  • Getting the care you need

    No one cares about your health more than you do. To become a truly effective patient, you've got to be deeply invested in promoting your own health.

    Learning as much as possible about your condition is a simple matter of self-preservation. Even under an ideal health care system (which, most assuredly, we don't have,) doctors won't always have the time or the inclination to discuss every important aspect of all your medical conditions. The more you teach yourself about those conditions, the better off you'll be. You'll be better able to interpret what your doctor is saying, and you'll even be able to steer your discussions into the areas that are most pertinent to you. You'll have a better understanding of what your doctor thinks should be accomplished, and a better grasp of what you can do to help accomplish it. Knowledge allows you to become an active participant, rather than a passive one, in managing your health care.

  • Questions to ask about Cost

    Bringing up your financial concerns to others is difficult — especially if you don’t know what to say, or who to ask. It's not always clear who the best person is to answer your questions, so talking with your doctor is a good start. Try starting the talk by saying: “I am worried about costs related to my treatment. Can we talk about my concerns?”

    Your doctor may not have all of the answers to your financial questions but they can guide you to help you get the best possible information. And, people from your medical aid company can help on questions about your specific health care coverage.

    Next, use the questions below to help focus the discussion. You don’t need to ask all of these questions – just choose the ones most important to your diagnosis and your financial situation. Select the ones you are most concerned about, and ask those first. If you think the doctor is the best person to answer your questions, let the doctor’s practice know ahead of time that you have some questions that you’d like to ask the doctor during your appointment, so enough time can be scheduled.

  • Medical Aid coverage and medical bills

    Who handles concerns and questions about medical aids in the practice?

    Will this person be able to help me work with my medical aid company?

    Will this person help me figure out my medical bills and the codes on the bills to make sure they are correct?

    If a claim is denied, who can help me file an appeal?

    Is there a limit to how much my medical aid will cover for my treatment? If so, are my medical bills likely to reach that amount?

  • Doctor appointments

    Does the doctor have a practice billing policy in place?

    Do they offer any payment plans?

    How much is my co-pay for each visit?

    When is this payment due?

    Will I be billed separately for laboratory tests, such as blood tests? Are they covered under my medical aid option?

  • Treatment costs: General

    Who can help me estimate the total cost of the recommended treatment plan?

    If I cannot afford this treatment plan, can we consider other treatment options that don’t cost as much?

    Does my medical aid need to approve all of the treatment before I begin the treatment?

    Is the treatment facility you are recommending in my health plan’s network?

    If I need to be admitted into the hospital, what is covered under my medical aid plan?

    If I receive treatment as an outpatient, what is covered under my medical aid plan?

  • Prescribed Minimum Benefits

     

    The Prescribed Minimum Benefits (PMB) legislation was introduced to ensure that patients receive a minimum of care for a defined group of conditions or injuries, despite the registered benefits of their medical scheme plan option. The legislation forms part of the Medical Schemes Act No 131 of 1998 (amendments to regulations 7 & 8 were published in the Council for Medical Schemes Circular 9 of 2003).  [view legislation]

    With increasing healthcare costs & new technology, as well as varying benefit designs on medical scheme plan options, patients find themselves in the situation, much earlier in the year than before, where they have run out of insured benefits. It is imperative that patients ensure that they receive their cover as per the PMB legislation from the beginning of the year – and not wait until their benefits or saving accounts are depleted.

    What conditions and illnesses are covered?

    The following has to be covered in full by the schemes

    • All emergency medical conditions
    • 270 medical and surgical conditions (including the 25 chronic diseases)

    This includes more than 5,500 ICD-10 diagnoses codes. An ICD-10 code is the diagnoses of a patient’s condition in a code format.

    An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or an operation. If the treatment is not immediately available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death.

    The list of 270 medical and surgical conditions (also referred to as the Diagnosis Treatment Pairs (DTP’s) [view list of 270 conditions only] includes all major conditions, cancers and injuries of the heart, brain, lungs, bones and other vital organs. For these conditions, it is important to ascertain which diagnostic codes are included and exactly what treatment and care is included. [view list of all diagnoses codes and legislated care]

    The 25 most chronic conditions listed on the Chronic Diseases List (CDL conditions) are included in the 270 PMB conditions. They are however specified in more detail in the form of legislated treatment steps.  

    What has to be paid?

    All costs related to the:

    • Diagnosis
    • Legislated Treatment
    • Care costs

    The scheme must cover the costs incurred during the process of making the diagnosis of a PMB condition. This includes, but is not limited to, consultations, blood tests, ECG’s, X-Rays, Scans and even diagnostic procedures (like gastroscopies and colonoscopies).

    The treatment is well-defined for the 25 chronic diseases, including comprehensive care like the diabetic patient’s annual follow-up at the ophthalmologist and the regular blood tests for the patient with renal failure.

    For the other PMB’s it is important to read the legislation carefully, in order to establish what is covered for your specific condition Treatment can be very specific (i.e. chemotherapy or 21 days in hospital) or comprehensive (i.e. medical, surgical). Where surgery is included, even the costs for the prosthesis & other products must be covered in full (provided that it falls within the level of care which would have been provided in the academic state hospitals)

    Medical treatment includes prescription drugs & medication. Included also is healthcare services like cost of rehabilitation (physiotherapy for the spinal injury patient & speech therapy for a stroke patient).

    The care costs for your condition includes all the additional products required to manage your PMB condition (like plaster cast, insulin syringes, colostomy bags, wound dressings and bandages).

     

    Schemes Rights and Responsibilities

    Schemes are allowed to put the following measures or processes in place to manage costs:

    • Treatment Protocols & Benchmark treatment

    • Formularies (list of specific medicines)

    • Pre-authorization or Registration processes

    • Appoint designated service providers (DSP’s) to render services for the PMB conditions to the patients on a specific plan option. A scheme can thus appoint (and insist) that a member goes to a specific group of GP’s, specialists, hospitals, pharmacies, etc (even those in the State sector)

    • Impose a waiting period or exclusion if you have recently joined the scheme.

    • Schemes have to cover, at minimum, the standard of care provided in the State sector, including investigations, prosthesis & medication.

    If a patient adheres to the above, then the scheme has to pay the costs in full.

    Certain schemes are excluded from the PMB legislation as most of the bargaining council schemes do not fall under the regulatory framework of the Department of Health. [list of schemes excluded]

    The scheme does not always have to pay in full and may impose a co-payment when a patient voluntary* chooses to

    visit a non-DSP (e.g. not to go to the scheme’s designated GP) or

    use non-formulary medication (e.g. patient does not want to use the scheme’s formulary drug which is maybe a generic drug but opts for a more expensive drug – without trying the generic medication first).

    The co-payment can be the difference between the amount charged and the chosen DSP’s fee or a % of the non-DSP’s fee.

    However the scheme must pay the costs in full if:

    • the formulary medication wasn’t effective, or

    • the patient had no choice but to visit a non-DSP (an involuntary* non-DSP service)

    A service is seen as *involuntary when

    • The scheme hasn’t appointed any DSP

    • DSP couldn’t render the services without unreasonable delay

    • Service is not available from the DSP

    • Immediate care or treatment was required

    • DSP not available within reasonable proximity (usually this viewed as approximately 20km but is not a strict rule)

     

    Patients' Rights and Responsibilities

    Patients cannot expect healthcare professionals to be fully aware of the 300 different medical scheme plans’ appointed DSP, pre-requisite or insured rates.

    It therefore remains the patients’ responsibility to familiarize themselves with the PMB-related processes and conditions of their individual schemes.

    Patients are therefore advised to

    • Obtain the correct and clinically appropriate ICD-10 code from their service providers (e.g. doctor and pharmacist)

    • Enquire with their scheme whether it is a PMB condition; if so, are there any pre-requisites like

      • First registering the condition as a PMB

      • Having to go to certain DSP’s (Designated Service Providers)

      • Using certain medication first (e.g. generic medicines)

      • Treatment Protocols and Formularies

    • If it is a PMB, ensure that the above ICD-10 code is supplied on all PMB condition related accounts like the X-Ray from, prescription and blood test forms.

    • Ensure that the scheme processes and reimburses all PMB-related accounts correctly which means

      • Not from savings accounts

      • Where appropriate, ensure that the scheme pays your service provider in full for DSP and Involuntary non-DSP services.

      • In line with the PMB restrictions on waiting periods and exclusions [view PMB impact on waiting periods]

     

    Schemes tend to demand considerable paper work when

    • a healthcare provider tends to ask more than the rate at which your plan is insured for or

    • when the patient request a benefit which is not part of the standard insured plan option. It remains the patient’s responsibility to ensure that the necessary validating paperwork is provided.

    Best is to agree with your healthcare service provider on the assistance required from him or her, and at what costs if any.

     

    Doctor's responsibility

    There are no fixed regulated prices for services rendered by doctors; sometimes a scheme might have contracted with some doctors or specialists at certain rates. It remains the responsibility of the patient to know what rates the scheme is prepared to pay. Cost for these services remain the responsibility of the patient.

    In terms of section 6 of the National Health Act of 2003 and section 53 of the Health Professions Act, the treating doctor must inform the patient the fee for which he intends charging for services to be rendered. Obviously within medicine one must allow for acceptable deviances.

    Doctors should also inform the patient of the long term benefits of quality care with a co-payment (for expert service or non-formulary medication) vs Short term saving by eluding a co-payment.

     

    And if the Medical Scheme does not comply?

    Should you not be successful in solving your PMB-related queries with the Call Centre of your scheme, then address it with the scheme’s principal officer and the scheme’s dispute resolution committee.

    If a patient or service provider fail to find an acceptable resolve with the applicable medical scheme, then contact the Department of Health’s regulatory body overseeing medical schemes, the Council for Medical Schemes, on (012 431 0500)

    Case studies and more information

    The following two cases studies illustrate many of the various aspects and issues to be considered with PMB conditions, their treatment and medical scheme actions.

    Case study 1: Patient with a Hernia

    Case study 2: Care for patient with Diabetes Mellitus

    For more information on PMB’s and Frequently Asked Questions, visit the website of the Council for Medical Schemes.  [visit CMS website]

  • ICD-10 Diagnosis codes

    What is an ICD-10 code?

     

    An ICD-10 code is the diagnoses of a patient’s condition in a code format. There are more than 45,000 ICD-10 codes and combinations, so please appreciate and understand your healthcare provider’s time to making sure that they give you the correct code when treating you. 

    ICD-10 stands for International Classification of Diseases and Related Health Problems (10th revision).

    It is a coding system developed by the World Health Organization (WHO), which translates the written description of medical and health information into standard codes. For example, H65.9 is for acute otitis media (middle ear infection) or S62.50, which is the code for a closed fracture of a thumb. 

    According to Regulation 5F of the Medical Schemes Act of 1998, all accounts submitted to your medical aid for the services rendered to you has to contain a diagnosis in the form of an ICD-10 code. Medical Aids can legally decline a payment for a claim if no ICD-10, or an incorrect ICD-10 code has been submitted on your claim. 

    An ICD-10 code consists of an alphabetical and numerical character. The alphabetical character will always be in the first position, followed by the numerical characters H71. It can consist of three, four, or even five characters – and it has to be specified to a maximum character level where possible. Sometimes it even requires more than one code for one condition.

     

    The ICD-10 code is also the “password” to your PMB benefits and rights.

     

    The ICD-10 codes provide accurate information on the condition you have been diagnosed with and these codes help your medical aid to determine what benefits you are entitled to and how these should be paid. This becomes very important if your condition is a PMB condition, as these can only be identified by the correct ICD-10 codes. If no ICD-10 codes are provided, or if the incorrect ICD-10 codes are given, the PMB-related services could be paid from the wrong benefit such as your medical savings account, or it might not be paid at all if your day-to-day or hospital benefit limits has been exhausted.

    It is not a legal requirement for your health provider to provide the ICD-10 code on a prescription, blood test or X-Ray request form.  

    Even if you pay the doctor upfront, it is essential that your healthcare provider gives you, or submits an account to your medical aid with the correct ICD-10 codes in order to get it paid. In the case of your illness being diagnosed as a PMB, the importance of the correct code is essential if you are in need of having, for example, a second scan and your medical aid will normally only pay for one scan per family per year. If the correct code is given, your medical aid will be obliged to cover and pay for the cost of the second scan as well. 

     

    What if you don’t want your clinical information made known?

     

    You have the right to inform your healthcare provider that you do not want to have the ICD-10 code disclosed on your account. In such a case, your healthcare provider will then use the code U98.0 (Patient refusing to have clinical information disclosed). By requesting this, your medical aid might not pay the account if certain benefits have been depleted.

  • Medical Schemes

    The Patient / Beneficiary

      • The person in the family contracting with the scheme is called the principal member. His / her spouse, children and other family members are defined as dependants. Towards the middle of 2010, about 8 million patients (principal members and dependants) are members of South African medical schemes.

      • Members are required to vote when the rules of the scheme require their consent, e.g. on rule amendments, liquidation, and amalgamation. Voting may occur at the AGM or SGM or by posted ballots. Rules provide for instances where a beneficiary has a complaint against the scheme; they must describe the procedures for dispute resolution. If the member is unsatisfied with the decision of the disputes committee of the scheme, s/he can lodge a complaint against the decision with the CMS which will then be handled as per Section 47 of the Medical Schemes Act.

      • In general, patients/beneficiaries

        • must know the rights and responsibilities of the other party be that the scheme, administrator or managed care company

        • has the right to (and responsibility to) a scheme, administrator or managed care organisation (MCO) to treat each other with respect, professionalism and in confidentiality

      • Further to the above, the following patients’ rights & responsibilities apply:

     

     

    Patient rights

    Patient responsibilities

    Medical schemes / Administrators / Managed care companies / Brokers

     

     

    Right to membership (unless it is a close or restricted scheme)

    Must provide accurate & complete info; and disclose all info with membership application

     

    Right to a full copy of the scheme rules and any other scheme-related info

    Cannot belong to two medical schemes at the same time

     

    They cannot be discriminated against unfairly

    To pay their monthly contribution

     

    Right to move between options within their scheme on 1 January of each year

    Act honestly and never submit fraudulent claims (may result in suspended membership)

     

    Principal members can attend and vote at the Annual General Meeting (AGM) of their scheme

    Members must ensure that claims for services are submitted to the scheme within 4 months of the service date

     

    Right to call a Special General Meeting

    Membership is not transferrable

     

    Know if your scheme is self-administered or uses a third-party administrator

    Know what the scheme remains legally liable to you

     

    Obtain any information on request within a reasonable period of time

    Know the managed care requirements you have to adhere to

     

    If uncertain about anything / need advice, ask If unhappy about anything, speak out.

    Know the reimbursement rates to the various service providers as defined in your plan option.

     

    Know where to go when you have questions or want to lodge a complaint.

    Comply with managed care procedures to avoid penalties and personal liability, and to ensure that your benefits are never refused or limited

     

    Insist that scheme and third parties comply with the rules of the scheme and the Medical Schemes Act

    Read all correspondence – know the services performed by the administrator and MCO on behalf of your scheme.

     

    Play by the rules

     

     

    Join a scheme without using a broker. Switch brokers if you are not satisfied with service.

    Ensure the broker is licensed by the FSB to sell health business

     

    Insist on the broker telling you if s/he is independent or tied.

    Understand what the broker will do for you in terms of his/her agreement with the scheme.

     

    There must be mutual consent between you and the broker in respect of extra services and payment of additional fees

     

     

    Council for Medical Schemes

    • The Medical Schemes Act No 131 of 1998 governs the SA medical scheme funding industry, in that it

      • Consolidates the laws regulating registered medical schemes

      • Provides for the establishment of the Council for Medical Schemes (CMS) as a juristic person

      • Providers for the appointment of the Registrar of the CMS

      • Makes provision for the registration and control s certain activities of medical schemes

      • Protects the interest of beneficiaries of medical schemes

    • The governance of the Council is vested in a board appointed by the Minister of Health, consisting of a Non-executive Chairman, Deputy Chairman and 13 members. The Executive Head of the Council is the Registrar, also appointed by the Minister in terms of the Medical Schemes Act. The Council determines overall policy, but day to day decisions and management of staff are the responsibility of the Registrar and the Executive Managers.

      • Roles of the Council for Medical Schemes are to:

      • protect the interests of medical schemes and their members;

      • monitor the solvency and financial soundness of medical schemes;

      • control and co-ordinate the functioning of medical schemes in a manner that is complementary with the national health policy;

      • investigate complaints and settle disputes in relation to the affairs of medical schemes;                    

      • collect and disseminates information about pri 

      • collect and disseminates information about private health care in i>

      • make rules (that are in line with the Medical Schemes Act) with regard to its own functions and powers;

      • make recommendations to the Minister of Health on criteria for the measurement of quality and outcomes of the relevant health services provided for by medical schemes

    • The above roles and responsibilities are handled by various units within the CMS.

    • Medical schemes submit the changes to their plan options, benefits and premiums (contributions) for the next year to the CMS every year around September / October for evaluation and approval. The Benefits Management Unit has a comprehensive function of dealing with medical schemes' rules, benefits and contributions by:

      • The registration of medical schemes in terms of the Medical Schemes Act & regulations thereto

      • The approval & registration of amendments to the rules & benefit options of medical schemes.

      • The unit also considers, facilitates and oversees the amalgamation of and transfers between schemes and oversees the process of voluntary liquidation of schemes.

      • Review compliance of benefits and exclusions with PMB regulations

      • Render clinical advice and support

      • Contributing to policy on benefit design

      • Contribute to the implementation of the Risk Based Operating Framework at CMS

    • The main objective of the Legal Unit is to Protect the Public; and duties of its two sub-units (1) Legal services and (2) Complaints & Adjudication are:

      • Provision of legal support to CMS and the Office of the Registrar

      • Facilitation of judicial process in matters concerning the enforcement of the Medical Schemes Act, particularly within the enforcement context

      • The provision of administrative and secretariat support to the Council and Appeal Board with respect to hearings and other ancillary matters

      • Dealing with complaints raised by members of the public - receiving, analyzing & resolving them

      • Investigating inconsistencies with the Medical Schemes Act

      • Ensuring the schemes have dispute committees in place

      • Monitoring the treatment of beneficiaries to ensure fair treatment, and

      • Ensuring that the provisions of the Act are interpreted and applied correctly

    • The Financial Supervision Unit is responsible for:

      • Monitoring the solvency and financial soundness of medical schemes.

      • Analyzing financial data of medical schemes, reporting the findings therefore and ensuring adherence to the financial requirements of the Act.

    • The role of the Accreditation Unit is to:

      • Accredit brokers, administrators of medical schemes and managed care organizations.

      • Investigate complaints against accredited entities listed above

      • Develop standards, criteria and service level for accredited entities

      • Ensure compliance by entities with conditions for accreditation

      • Render advisory services with regard to accreditation matters

    • The Compliance Unit ensures that schemes, administrators and brokers comply with the Medical Schemes Act and regulations, specifically in respect of the areas designated by the office as priority areas namely, non-healthcare expenditure, governance, general non-compliance, the risk assessment framework, enforcement of rulings made by the Registrar and the demarcation between medical schemes and insurers.

    • The Compliance Unit does that by:

      • Communicating with schemes, administrators and brokers on an ongoing basis;

      • Engaging the above in dialogue and discussions in respect of contentious/priority areas;

      • Training of Boards of Trustees;

      • Consumer Education and Information sessions for Health Providers

      • Specific enforcement actions.

    • The Risk Equalisation Fund (REF) team is preparing the office and the industry for the introduction of a system of risk equalization; and involves

      • The building of the organization that will deal with REF transfers

      • The building of the required IT systems

      • The legislative process that will ensure that enabling legislation is promulgated

      • The analysis of REF shadow data submissions

    • The registrar of the CMS releases the Annual Registrar’s Report around September each year in which an overview of schemes statistics, costs and trends are provided. The current (October 2010) registrar of the CMS is Dr Monwabisi Gantsho.

    Contact details

    Telephone number     (012) 431 0500 / 0861 123 267 (Shared Call)

    Fax General:              (012) 430 7644 or

    Fax Complaints:         (012) 431-0608

    E-mail Enquiries:        support@medicalschemes.com

    E-mail Complaints:     complaints@medicalschemes.com

    Postal Address           Private Bag X34, Hatfield, 0028

    Physical Address       Hadefields Office Park, Block E, 1267 Pretorius Street, Hatfield, 0028

    Website:                     www.medicalschemes.com

     

     

    Medical Schemes

    • Medical schemes are not-for-profit entities which operate like trusts and undertake liability on behalf of beneficiaries in return for a monthly contribution. Schemes are there for the benefit of beneficiaries. The relationship between schemes and beneficiaries is governed by the Medical Schemes Act (Act 131 of 1998) and the registered rules of the scheme. 

    • The majority of medical schemes (representing about 75% of all insured lives) are members of the medical scheme’s representative body, the Board of Healthcare Funders. The BHF has no regulatory powers and act as a voice on behalf of its member schemes but has no power to regulate or decide on behalf of its member schemes.

    • A scheme is managed by a Board of Trustees. Principal members elect trustees, and at least half the Board must consist of members of the scheme. Trustees are entrusted with members' money to manage it well and ensure al beneficiaries enjoy adequate cover based on the principles outlined in the extract of the Act above.

    • The Board and principal officer can amend the rules of the scheme by resolution but any amendments must be registered by the Council for Medical Schemes (CMS) before they can be enforced. As the regulator of the industry, the CMS must ensure that every scheme rule is fair to beneficiaries and does not discriminate against any of their rights.

    • Every scheme is required to hold a reserve equaling at least three times the total contribution income that it receives in a month – this roughly equates to 25%.

    • Each benefit option must be self-sustainable in terms of financial performance and size of its membership. Each option must also allow for a minimum set of benefits. These guaranteed benefits are called prescribed minimum benefits or PMBs. Extra benefits over and above PMBs are instituted by the Board. These can be structured in various ways but they are essentially governed by the rules of the scheme. Registered rules must be consistent with the Medical Schemes Act and its Regulations.

    • Open medical schemes are open for any person wishing to join a medical scheme provided that they can afford the premiums.

    • Closed or restricted are exclusive on its membership; and are not open to the public. This is very common with employers (e.g. only Sasol employees may belong to Sasolmed) or closed groups / professions (e.g. only chartered accountants are members of CAMAF).

    • Self-administered schemes do not need to be accredited, but they must comply with the same administration standards and are subject to the same on-site evaluation of compliance as third-party administrators. 

    Rights & Responsibilities of Scheme

    • Open schemes cannot deny entry to any person that applies for membership. They therefore face the risk of anti-selection from the public.

    • The measures to manage anti-selection are waiting periods (general or condition-specific) and late-joiner penalties. A general waiting period can last up to three months; condition-specific waiting periods go on for up to 12 months. When members move between schemes, there is a limit to the waiting period that a scheme may apply and how it affects the provision of PMBs (see table).

    • Schemes may terminate your membership if you do not pay your contributions or if you do not disclose material information when applying for membership.

    • Boards can negotiate with healthcare providers for preferential rates for PMBs and nominate such providers as the preferred or designated service providers (DSPs) of the scheme.

    • Schemes may also use other mechanisms to manage the cost of claims, e.g. pre-authorisation, formularies, protocols, pro-rating benefits for joining the scheme mid-year, and applying deductibles and co-payments.

    • Schemes are required to operate within the bounds of the Medical Schemes Act and their registered rules. The Board is responsible for ensuring that the rules provide for the benefits that were intended - and certainly all PMBs.

    • The principle of community rating is another cornerstone of the Act. It requires schemes to base their contributions only on income and/or family composition (number of dependants), or both. This ensures that beneficiaries are not unfairly discriminated against on one or more arbitrary grounds such as race, age, gender; marital status, ethnic or social origin, sexual orientation, pregnancy, disability, and state of health.

    • The lines of communication between beneficiaries and their scheme must always be open. Schemes have the responsibility to provide proof of membership to beneficiaries as well as copies of their rules and financial statements.

    • They must also always act in the best interest of beneficiaries, e.g. by ensuring that all information is kept confidential and all services are indeed available and accessible to their beneficiaries, especially in cases where the scheme nominates a DSP to provide PMBs to its beneficiaries.

    • The sustainability of a scheme is of paramount importance. Boards must ensure that their schemes remain solvent. The Medical Schemes Act has further requirements relating to the financial performance of each benefit option and the size of the scheme.

    • Trustees must exercise their fiduciary duty in making business decisions

    SUMMARY

    Can the medical scheme impose the following waiting period?

    Can this waiting period include PMB conditions?

    History of patients’ previous medical scheme coverage

    General waiting period for 3 months

    Condition-specific for 12 months

    New applicants, or

    Persons not members on any scheme for preceding 90 days

    Yes

    Yes

    Yes

    Applicants who joined new scheme within 90 days from leaving previous scheme but were members for < 2 years at previous scheme

    No

    Yes

    No

    Applicants who joined new scheme within 90 days from leaving previous scheme and were members at previous scheme for > 2 years

    Yes

    No

    No

    Change of benefit option

    No

    No

    No

    Child-dependant born during period of membership

    No

    No

    No

    Involuntary transfers due to change of employment or employer changing schemes

    No

    No

    No

    • Before a waiting period query is forwarded to the SpesNet Healthcare Help line for assistance, you need to establish the following:

    • With regards to the condition / diagnosis

      • Is it a known (pre-existing) or new condition?

      • Is it a PMB condition or not?

    • Prior to joining the new medical scheme

      • For how long was the patient without any medical scheme coverage?

      • Was the patient on his/her former scheme / schemes for a period of longer/ shorter than 2 years in total?

    • A full list of all registered medical schemes is available on the CMS website:

    http://www.medicalschemes.com/Consumer_Assistance/RegSchemes.aspx

     

    Medical Scheme Administrators

    • Medical scheme administrators are privately owned companies (with a profit objective to their shareholders) with the skills, infrastructure, and capacity to render a full range of administration services to schemes in compliance with prevailing legislation.

    • They are accredited by the Council for Medical Schemes (CMS) in terms of the Medical Schemes Act if they meet the following criteria - they must:

      • be based in South Africa (for jurisdictional reasons);

      • be fit and proper;

      • provide services that are clearly distinct from others contracted by the scheme (e.g. managed care and broker services);

      • maintain a financially sound position; and

      • have the requisite resources, systems, skills, and capacity in place

    • Administrators perform a variety of administration functions as per their written contracts and service level agreements with schemes.

      • They utilise comprehensive and integrated information technology systems capable of performing all administration, financial, and management functions.

      • Medical scheme administrators maintain member records. Their systems can drill down to detailed information on an individual member It is the administrator who processes your application for membership and also suspends and terminates it.

      • Administrators collect the monthly member contributions and manage their allocation and reconciling. They ensure that outstanding amounts are collected.

      • In terms of claims administration, administrators make sure that their systems operate in accordance with the rules of the scheme, its registered benefit options, and any limitations it may have. Their systems must accurately assess and allocate claims and benefits.

      • Administrators regularly report on the financial position of their scheme(s). They must produce statutory returns and monthly management accounts.Their operating and financial management systems must therefore be interfaced on a regular basis, i.e. they must marry financial information with membership, contributions, and claims transactions.

      • Their information security policy must ensure sufficient access control and confidential treatment of patient information at all times. Administrator systems must be flexible and capable of taking on additional functions.

    • Before the Medical Schemes Act became enforce-able in 2000, administrators were not subject to any form of regulatory oversight. The only legal binding force was the contract between the administrator and the scheme. This arrangement proved inadequate as certain administrators too often held schemes at ransom without proper recourse being available to the schemes. It thus became necessary to legislate the relationship for institutional safety (to level the playing fields), given the impact of unscrupulous administrators on medical schemes.

    • The first step was to determine critical performance areas and minimum standards for accreditation to assess the performance of administrators objectively, determine requirements for individual accreditation, and ensure their ongoing compliance with regulatory provisions. Today, administrators are held accountable for everything they do or fail to do, and if they do not comply with accreditation requirements, the

    • The CMS may suspend or withdraw their accreditation. The regulatory framework governing the behaviour of administrators keeps evolving. Accreditation requirements are enhanced to conform to regulatory changes.

    • The systems and infrastructure required are sophisticated and expensive, and administrators should utilise economies of scale to offer a more cost-effective administration function.

    • Some medical schemes do not use administrators. A self-administered scheme undertakes all administration functions with its own resources.

    • Rights of administrator

      • You have the right respected at all times.

      • Place your own interests first - but not at the expense of beneficiaries.

      • Know your responsibilities towards beneficiaries.

      • Ask for the information you need.

      • Insist that applicants disclose fully the information you require, including their health history.

      • Insist on accurate and comprehensive information from the beneficiary.

      • Know the rights and responsibilities of the beneficiary towards you.

    • Responsibilities of administrator

      • "Know thyself" - distinguish between the scheme and yourself.

      • Know your rights and responsibilities towards beneficiaries. Respect the rights and responsibilities of beneficiaries. Play fair

      • Communicate. And do it well: use everyday language; explain technical terms; simplify complex processes and conditions.

      • Keep beneficiaries informed. Answer their queries; advise; provide guidance.

      • Help the beneficiary understand. Clarify. Keep it simple.

      • Provide accurate information - always.

      • Set up an effective call centre.

      • Ensure beneficiaries know about the scheme website.

      • Publish accurate information on the scheme website.

      • Explain prescribed minimum benefits (PMBs) and trends in the industry.

      • Clearly communicate requirements about network options, designated service providers (DSPs), limitations, option requirements, drug formularies, pre-authorisation, and protocols.

      • Ensure membership card reflects all relevant information.

      • Distribute documents to beneficiaries in good time, including the scheme rules and its annual

      • financial statements.

      • Do not confuse or mislead beneficiaries.

      • Ensure the scheme's marketing material is factually correct, unambiguous, and relevant to scheme rules.

      • Do not withhold information. Place yourself in the beneficiaries' shoes and tell them everything they need to know to make informed decisions.

      • Do not ask inappropriate questions, e.g. about unrelated business such as insurance cover

      • Respond to enquiries timeously

      • Manage complaints effectively and promptly. Address all complaints until the beneficiary has been put at ease.

      • Make sure you are always compliant with the Medical Schemes Act and other applicable legislation.

      • Provide a reliable and secure administration service in accordance with accreditation standards and your contract with the scheme(s).

      • Capture and assess all claims and pay them according to the scheme rules.

      • Ensure all financial data is properly recorded.

    • A full list of all registered administrators is available on the CMS website:

    http://www.medicalschemes.com/Consumer_Assistance/Administrators.aspx

     

     

    Managed Care Organisations

    • MCOs are commercial entities which determine if the treatment being sought by the patient and his/her healthcare provider is indeed necessary and appropriate, and whether the scheme should fund it or recommend alternative treatment.

    • MCOs are accredited by the Council for Medical Schemes if they meet certain criteria. They must, for instance, be financially healthy. Their technology and business models are scrutinised and verified with comprehensive standards to protect the interests of beneficiaries.

    • MCOs contract with medical schemes to provide healthcare services to their beneficiaries in a manner which introduces clinical and financial risk management according to rules- and clinical management-based programmes (clinical expertise based on proven scientific grounds and acceptable best practice).

    • Pure MCO’s include companies like MSO and Denis. Sometimes medical scheme administrators will render their clinical risk management services to a scheme through a separately registered company like Metropolitan Health Administrators and Medscheme whose clinical risk management services are rendered to schemes through Qualsa and Medscheme Health Risk Solutions (previously known as Solutio).

    • Managed care implies expert interventions such as:

      • pre-authorisation for certain procedures;

      • case management (clinical monitoring of patient while s/he is treated in terms of the managed care programme);

      • hospital management (observing and managing the recovery of patient in hospital after surgery);

      • management of diseases (e.g. cancer; chronic conditions, HIV/AIDS);

      • pharmaceutical benefit management (determining if the prescribed drugs are appropriate and effective); and

      • applying business intelligence with expert protocols and formularies to verify claims which the scheme has been asked to pay.

    • The above clinical and financial risk management solutions are to facilitate appropriate care within the constraints of what the scheme can afford. These processes and experts should however be clinically appropriate. MCOs should use documented clinical review criteria founded on evidence-based medicine to determine the appropriateness of the treatment being sought. At the same time they must take into account cost-effectiveness and affordability. They must also make provision for alternative treatment in exceptional circumstances where a protocol or formulary drug proves ineffective and/or harmful to a beneficiary - without penalising the beneficiary. MCOs have their own processes and rules but a decision of the scheme can modify these.

    • Anyone must be able to access (on demand) information on:

      • their protocols;

      • their medicine formularies;

      • formulary inclusions and exclusions (drugs available to the beneficiary);

      • any limitations on the rights of beneficiaries to treatment;

      • restrictions                 on care that the beneficiary can obtain; and

      • the services that the MCO provides, including formalities that must be complied with.

      • Formalities determine, for instance, how the beneficiary must register for a health management programme, and how treating doctors should motivate for pre-authorisation.

    • MCOs must apply clinical expertise (evidence-based medicine and good clinical practice) and demonstrate that they add value to their client scheme(s) rather than show mere cost savings without improving the health outcomes of beneficiaries. Their interventions must benefit both parties.

    • MCOs intervene in different ways. They often accept and manage risk for certain services that the scheme has transferred to them. They render or contract specialised services to other expert healthcare providers. They verify claims in terms of managed care interventions to ensure that what the scheme pays, is aligned with such interventions

    • Medical schemes do not have to outsource managed care. They may render - and thereby accept responsibility for - some or all managed care services themselves. Some administrators are also capable of providing managed care services

    • Rights of MCO

      • You have the right to have all your rights respected at all times.

      • Place your interests first - but do not prejudice beneficiaries by doing so.

      • Know your responsibilities towards beneficiaries.

      • Request the information you need.

      • Insist on beneficiaries being honest with you.

      • Know the rights and responsibilities of the beneficiary towards you.

    • Responsibilities of MCO

      • Know your rights and responsibilities towards beneficiaries.

      • Respect the rights and responsibilities of beneficiaries.

      • Ensure beneficiary information is kept confidential.

      • Conduct yourself ethically and within the bounds of legislation - always.

      • Comply with the Medical Schemes Act and other relevant laws at all times.

      • Perform contractual obligations in respect of beneficiaries.

      • Ensure beneficiary is not held liable for any sums owed in terms of your agreement with the scheme(s).

      • Keep beneficiaries in the loop. Do not keep them waiting or guessing.

      • Inform beneficiaries of latest developments and treatment for conditions.

      • Help beneficiaries understand your role, the programmes you offer; and the outcomes of interventions.

      • Clarify processes, reasons, registration on programmes, and pre-authorisation.

      • Explain the benefits of health management initiatives.

      • Attend to queries promptly.

      • Be open, honest, and considerate at all times.

      • Use ordinary language - you need to understand each other

      • Balance the interests of your client scheme(s) with those of beneficiaries, treating both the same way.

      • Make clinically justifiable decisions.

      • Keep proper records of your activities

    • A full list of all registered managed care companies is available on the CMS website:

    http://www.medicalschemes.com/Consumer_Assistance/MCO.aspx

     

    Brokers

    • If you belong to a medical scheme, you should know that part of your monthly contribution goes to a healthcare broker. Make sure you are getting what you are entitled to.

    • Healthcare brokers are supposed to be highly specialised professionals who

      • introduce you to private health cover

      • tell you how to join a medical scheme.

      • provide ongoing advice to their existing clients - medical scheme members - about the benefits they are entitled to and the services offered by their scheme.

    • The bottom line is that brokers are there to represent members of medical schemes - and to always act in the members' best interests.

    • Upon joining a medical scheme, you can - but you do not have to - appoint someone as your broker If you do, the broker signs a contract and service level agreement with your scheme. Schemes pay brokers from the monthly contributions that members make to their scheme. The maximum remuneration of brokers is prescribed by law. The only other form of remuneration that brokers are entitled to is a direct payment from the member for additional services.

    • Brokers are accredited by the Council for Medical Schemes (CMS) because they operate in the medical schemes industry. But because they are financial service providers, they must also be licensed by the Financial Services Board (FSB) for "health business" in terms of the Financial Advisory and Intermediary Services (FAIS) Act. The FSB legislation provides for subordinate legislation that regulates the conduct of financial service providers and their fitness and propriety.

    • In terms of Section 65 of the Medical Schemes Act,1998, Act No 131 of 1998 the Minister of Health determines the broker fees. The fees for 2010 are R65.65 / month.

    • Regulation 28(7) published under the Medical Schemes Act, 1998, (Act Nr 131 of 1998) states: “A medical scheme shall immediately discontinue payment to a broker in respect of services rendered to a particular member if the medical scheme receives a notice from that member (or the relevant employer, in the case of an employer group), that the member or employer no longer requires the services of that broker".

    • The above means that a member may appoint a new broker in place of a broker previously appointed by a member, i.e. there must be an initial appointment prior to a subsequent broker substituting an earlier appointee. Similarly, when a member has been admitted to a scheme without the assistance of a broker, no other person or entity Is In a position to assume the role of agent representing the member in appointing a broker thereafter. Failure to comply with this provision undermines the law of agency principle which is enshrined in the Financial Advisory and Intermediary

    • There are two kinds of healthcare brokers.

      • Independent advisors are not attached to any particular scheme. They have contracts with many schemes and provide their clients with a choice of cover. (Member agents and employer agents fall in this category.)

      • Marketing agents are tied to a particular scheme or group of schemes and promote only the products of their contracted scheme(s).

    • Employers may appoint a broker to advise those employees who belong to a medical scheme. Such a broker has to be independent.

    • Since marketing agents promote only the products of a particular scheme, they are expected to tell you the truth about these products. Independent brokers are expected to give beneficiaries best advice, cognizant of their needs and financial circumstances.

    • Rights of broker

      • Right to have your rights respected at al times.

      • Balance your own interests with the best interests of beneficiaries.

      • Know the rights and responsibilities of the beneficiary towards you.

      • Insist that applicants disclose fully the information you require.

      • Insist on obtaining all documentation needed to fill out an application form.

    • Responsibilities of broker

      • Put the beneficiary first.

      • Know your rights and responsibilities towards beneficiaries.

      • Respect the rights and responsibilities of beneficiaries towards you.

      • Introduce yourself properly.

      • Are you an independent advisor? Do you have specific ties with certain medical schemes

      • With which scheme or schemes do you or your firm contract with?

      • Establish a relationship of trust.

      • Always act in best interests of beneficiaries.

      • Obtain duly signed appointment letter from beneficiary.

      • Obtain all information to be able to properly assess needs and affordability of beneficiary, and advise him/her accordingly.

      • Ensure every beneficiary is well-informed about scheme and its rules.

      • Do not make promises to the beneficiary on matters over which the scheme decides, e.g. waiting periods, late-joiner penalties, date of admission.

      • Clarify which services are excluded, e.g. submitting claims, handling enquiries, administration.

      • Keep up to date with developments in the industry, including the financial soundness of schemes, changes to benefits and contributions, and any factors which influence the relationship of the beneficiary with the scheme

    • A list of registered brokers is available on the website of the Council for Medical Schemes

    http://www.medicalschemes.com/Consumer_Assistance/FindBroker.aspx

     

    Lodging a complaint

    • An eligible complainant is a person who would be eligible to refer a complaint to the Council in terms of Section 47(1). The definition of a complaint is provided in Section 1 of the Medical Schemes Act, 1998

    • “complaint” means a complaint against any person required to be registered or accredited in terms of this Act, or any person whose professional activities are regulated by this Act, and alleging that such person has

      • Acted, or failed to act, in contravention of this Act; or

      • Acted improperly in relation to any matter which falls within the jurisdiction of the Council.”

    • Before submitting a complaint, especially patients, must:

      • Make sure you know and understand the rules of your scheme.

      • Read all correspondence from your scheme.

      • Study your benefits guide.

      • Familiarise yourself with the terms and conditions of the benefit option that you have chosen.

      • Make sure your contributions are paid in full and on time every month.

    • The Council does not act as “debt collector” for healthcare providers who cannot get their bills paid. The complainant must first endeavor to solve the issues with the accused party; and put all efforts in place to first exhaust all avenues put in place by the other party for any dispute resolutions including:

      • Phone the scheme

      • Write to the Principal Officer

      • Give full details of your complaint and include any supporting documents.

    • Only once these have failed or you are not satisfied with the outcome must the complaint be submitted at the CMS by any reasonable means such as a letter, telephone, fax, e-mail or in person from Mondays to Fridays during 09h00 – 16h00.

    Time limits for dealing with a complaint

    • The following are the official time limits but because of lack of resources and the sheer volume of complaints, the CMS can currently not manage complaints within the mentioned time limits.

    • The Registrar's Office must send a written acknowledgement of a complaint within 2 working days of its receipt, giving the name and contact details of the person dealing with the complaint (and attaching a copy of the procedure for handling complaints).

      • The Registrar's Office shall, within 4 days of receiving the complaint; analyse the complaint and refer the complaint to a medical scheme for comments, as prescribed by section 47 of the Medical Schemes Act, and afford the medical scheme 30 days to respond.

      • Where, on initial assessment the complaint it is found to be without merit, the complaint shall not be forwarded to a medical scheme. The complainant will be informed of the view of the Registrar's Office in this regard while making reference to the provisions of the applicable rules of the medical scheme as well as the relevant clauses of the legislation.

    • > Upon receipt of a response from the medical scheme, the Registrar's Office must analyse the response in order to make a decision or ruling. 80% of decisions will be made within 60 days of receipt of a response whilst 20% of decisions will be made within 90 days thereof.

    • Prior to the CMS making a ruling, a complainant will be provided with either:

      • A final response; or

      • A holding response which explain why we are not yet in a position to resolve the complaint and indicate when we will make further contact within our operational timelines.

    The final response

    • When the Registrar's Office sends a determination in a form of a ruling, a complainant is informed of a right to appeal against the decision of the Registrar to the Council should he/she be aggrieved by such decision, and that:

      • such an appeal must be lodged within 90 days of the Registrar's decision;

      • the operation of a decision that is subject of an appeal shall be suspended pending review by the Council.

    Appeal to Council

    • The Registrar's Office advises the disputants of the date, time and venue for the hearings. The said notice shall not be less than 14 days of the date of the hearing.

    • The disputants may appear before the Council and tender evidence or submit written argument or explanation to the Council in person or through a representative.

    • The Council may after hearing the appeal confirm or vary the decision concerned, or rescind it and give other decision as it may deem just.

    Appeal to the Appeal Board

    • The appellant has 60 days within which to appeal the decision of Council and must submit written arguments or explanation of the grounds of his or her appeal.

    • The Appeal Board shall determine the date, time and venue for the hearing and all parties will be notified in writing.

    • The Appeal Board shall have the powers which the High Court has to summon witnesses, to cause an oath or affirmation to be administered by them, to examine them, and to call for the production of books, documents and objects.

    • Appeal Board shall be heard in public unless the chairperson decides otherwise. The decisions of the Appeal Board are in writing and a copy thereof shall be furnished to parties.

     

  • Doctor charges

    What fees is your doctor allowed to charge?

    Doctors deal with patients who have different medical aid cover and patients who have no medical aid cover. Where a patient has some form of third party cover e.g. private medical aid, injury-on-duty cover, GAP cover, the treatment and the costs thereof can also be determined depending on whether the patient still has some cover left over for the specific treatment, or whether they have completely depleted their benefit cover for the year.

     

    Does the doctor charge “contracted in” fees?

    This is a common question asked by patients. Unfortunately the answer to how a doctor charges is not an easy one as it depends on many factors within the doctor’s practice. In the private medical aid market there are over 105 different medical aids with more than 300 different medical plan options. All these medical aids and these plan options have various ways in which they will cover and reimburse a medical doctor for the healthcare services rendered. For example;

    • Where the healthcare service was rendered (e.g. In or Out of hospital)

    • The speciality of the doctor (e.g. GP, Cardiologist or Orthopaedic Surgeon)

    • Whether the medical aid has a contract (an agreed upon fee) in place with the specific doctor and

    • If the hospital (where the service was rendered) is on the medical aids list of preferred hospitals.

    Because of all these variations in medical benefit cover and the different reimbursement rates applied by the different medical aids, patients should not always expect the doctor or practice staff to have all the information available on the different reimbursement rates and healthcare covered by the patient’s medical aid plan. 

    Even if your medical aid does cover a certain operation or procedure, the medical aid might decide not to cover all the codes charged for by the treating doctor. They might also impose co-payments on the patient like 20%, or an upfront payment of R5, 000.00 for in-hospital treatment. This depends on the medical aid plan rules the patient belongs too. 

    It is very important that the patient should enquire and discuss the healthcare treatment plan and the costs associated to the treatment with their doctor. This should be done and agreed upon before any treatment is given or undertaken. A patient is entitled to ask for a formal written quote from the treating doctor which includes the expected treatment envisaged and the cost of the treatment. 

    It is important for patients to understand than a pre-authorization number given by the medical aid for a procedure is not always a guarantee that they will necessarily pay all the costs incurred when undergoing a procedure or when consulting a medical specialist doctor. 

    Should your medical aid request that your doctor completes certain registration forms or has to provide a motivation letter to your medical aid, the doctor can charge for the additional paper work submitted.

    What should patients do?

    For patients with medical aid cover, the onus still remains on the patient to know what is covered on their plan and how much their medical aid will pay and if there are any pre-requisites or conditions that they may have to adhere to before seeking treatment. 

    Even if the doctor decides to send the account to the patient’s medical aid for payment, it still remains the responsibility of the patient to ensure that the account of the doctor is covered and paid for. In the event of the patients medical aid not paying the doctor directly, or only paying in part for the treatment given, or paying the patient directly and not the doctor, the patient is at all times fully liable for the full costs incurred and the doctor is legally entitled to charge interest and any other costs incurred in the recovery process in the event of an account not being settled in full by the patient.

    • In order to prevent any misperceptions or expectations, the patient should discuss the cost of the proposed treatment with the doctor upfront.  
    • If the patient has medical aid cover, they need to identify what portion their medical plan covers, what they don’t and what requirements the patient needs to take before treatment is undertaken e.g. pre-authorisation, co-pays,    medical benefit limits. 
    • To then agree with the doctor on what the envisaged fee and cost will be. The doctor might also decide to decrease the fee or the patient might be prepared to pay the portion difference which the medial aid does not cover. 
    • It is then advisable to ask for a written quote from the doctor before the treatment is undertaken. It is also important to note that during surgery, other interventions or actions might arise and which were not part of the written quote.

     

    Over and above the mentioned issues concerning costs and fees, patients do have further rights concerning their diagnosis, management and the treatment options available. One of these is the right to a second opinion if need be. 

    If a patient’s medical aid cannot clarify at which rates they are insured at, patients can submit complaints to the Council for Medical Schemes. complaints@medicalschemes.com; Tel 012 431 0500 

    If patients are uncertain of their rights and those of the doctor, or should they have any further questions, they should not hesitate to ask the practice staff or their doctor. 

     

Take some time to go to the tabs on this page and to familiarize yourself on what fees your doctor is allowed to charge for, your rights as a patient in our healthcare market place and the mandatory treatment cover you have under the PMB legislation.