Selfmed Glossary of Medical Aid Related Terms
Act 131 of 1998, better known as the Medical Schemes Act, came into effect on 1 February, 1999. All South African Medical Schemes are legally obligated to adhere to the Act and comply with all regulations passed by the Government Gazette.
An acute condition is a disabling condition, such as tonsillitis or appendicitis, which heals entirely after treatment.
Benefits are the medical services, procedures and/or medication that you are covered for in return for your monthly medical aid contributions. The benefits you receive are dependent on the particular medical aid plan you’ve chosen. Some medical aid options (plans) offer comprehensive benefits (both-day-today and in-hospital cover), while others offer only in-hospital benefits.
Capitation is a healthcare model that involves a managed care organisation paying a set amount of money to a group of healthcare providers. The fee-for-service healthcare model is the opposite of the capitation model.
A chronic condition is any condition which demands ongoing treatment, or treatment for a period of at least three months. Examples are Asthma and Diabetes.
Chronic Disease List (CDL)
The Chronic Disease List, or CDL, is an official list of 25 conditions and diseases that medical aid schemes may not exclude. In other words, medical schemes have to offer healthcare cover for these 25 conditions.
Chronic medication is the medicine that someone with a chronic condition (see definition) needs. A medical aid scheme has the right to limit its expenditure in terms of Prescribed Minimum Benefits (see definition) by controlling which medicines and treatment options are covered in terms of its schemes. Members might have to stick to a certain brand, or choose generic medicines, for example.
After you, as a Selfmed member, have paid for medical procedures, services or medicines, you can submit the receipt to Selfmed for reimbursement. Your claim will be assessed and processed, and depending on the particular medical aid option you are on, you will be reimbursed accordingly. Some service providers submit the claim directly to us, while in other instances it is up to you to submit the claim to Selfmed. In either case, claims are always the responsibility of the member.
Claims Paying Ability
A medical aid scheme’s claims paying ability refers to how many claims it can cover in any given month. Claims paying ability is calculated in terms of the medical scheme’s cash and cash equivalent resources.
A co-payment is a certain percentage of the cost of a medical procedure for which the member is held liable.
A medical aid plan that offers both day-to-day cover and in-hospital benefits is known as a comprehensive medical aid. A hospital plan is not a comprehensive medical aid plan, as it only covers members for in-hospital treatment.
By law, all the members of a particular medical aid scheme option have to pay equal monthly contributions. Community rating ensures that the sick and the elderly are not discriminated against.
Condition-specific waiting period
A condition-specific waiting period may be imposed on new medical aid members who have an existing medical condition when joining the scheme. During this waiting period, which may range from 3 months to one year, these members are not allowed to claim for any costs associated with the condition. Once this period has passed, the condition will be covered according to the benefits offered by the member’s chosen plan.
A consultation refers to any time you visit a medical practitioner, such as a doctor, dentist, gynaecologist, specialist, etc. Every practitioner charges a different set of rates for their consultations.
In terms of continual membership, principal members of a closed medical aid scheme have the right to stay on with the scheme once they have retired even if their contributions are no longer paid by their previous employers. Furthermore, the dependants will remain covered in the event of the principal member’s death.
If a doctor or a dentist is “contracted out”, he or she does not comply with the Council for Medical Schemes’ National Health Reference Price List (see definition).
A dependant is any individual who belongs to a principle member’s medical aid plan, and whose medical aid fees are covered by the principle member. For example, if a principle member adds their children to their medical aid plan, their children are the dependants on that plan. Individuals who qualify as dependants are spouses, life partners, children (including step-children, adopted children and foster children), siblings or parents of the main member.
This is a fixed amount that a member must pay upfront for certain, pre-determined medical procedures.
Designated Service Provider (DSP)
A medical aid’s Designated Service Provider is a set group of preferred healthcare providers from whom members can obtain co-payment-free, unlimited diagnosis and treatment in respect of the Prescribed Minimum Benefits (as set out in the Regulations to the Medical Schemes Act).
According to the Medicines and Related Substances Control Amendment Act, a medical aid scheme can only pay out medicinal claims if the medicine was dispensed by a medical practitioner with a dispensing licence.
Drug Utilisation Review, or DUR, is a way of establishing, monitoring and analysing the effectiveness of certain drugs in terms of successful drug therapy.
Elective surgery refers to any surgery that is non-essential, and which is opted for by a patient – for example, breast augmentation. These types of medical procedures are not covered as they are for cosmetic rather than medical purposes, and are not associated with a life-threatening condition.
Exclusions are medical conditions which a medical aid scheme is legally permitted to exclude from its health insurance offering. Examples are self-inflicted injuries and cosmetic surgery.
Global Credit Rating (GCR)
Global Credit Rating is a company that determines and rates a medical aid scheme’s capacity to pay out claims, or a hospital’s capacity to pay for medical treatments and services.
General practitioner (GP)
A general practitioner, or (GP), is a medical doctor who provides primary medical advice, treatment and care, and usually specialises in family medicine.
Unlike a comprehensive plan, which offers both day-to-day and hospital cover, a hospital plan offers only in-hospital benefits. Hospital plans cover the major cost of hospitalisation and as such are best suited to members who are healthy, do not often visit doctors, and who simply wish to have major medical benefits in place in the event of an emergency or unforeseen hospitalisation.
By law, every claim that is submitted to a medical aid scheme must include an ICD-10 code. The ICD-10 code system is based on a medical diagnosis of a global categorisation of diseases, and it was developed by the World Health Organisation in order to standardise the diagnostic process.
Late Joiner Penalty
According to the Medical Schemes Act (see definition), South African medical aid schemes may impose a late joiner penalty for people older than 35, who want to join the scheme. In order to minimise risk, this penalty is calculated in terms of how long the person has not belonged to a registered medical aid scheme – the longer without medical aid, the higher the imposed penalty.
Medical Savings Account (MSA)
A medical savings account (MSA) is where a member’s own money is kept aside to pay for day-to-day medical expenses.
Medical Scheme Rate (MSR)
Selfmed’s Medical Scheme Rate (MSR) is the rate at which we pay service providers. For example, if our MSR is 100% and a service provider charges 100% of MSR rates, the service will be covered in full. However, if a service provider charges 150% of MSR rates, the member will be responsible for covering the shortfall (known as the tariff shortfall).
National Pharmaceutical Pricing Index (NAPPI) codes are used to provide information about pharmaceutical and surgical products. This includes details about the manufacturer, registration, strength and dosage.
National Health Reference Price List (NHRPL)
The NHRPL is a national pricing system regulated by the Department of Health and the Council for Medical Schemes. Basically, the NHRPL stipulates the rates to which medical aid schemes must adhere in terms of benefit payments. However, medical service providers are not bound by this rate and some thus charge significantly higher rates. In such cases, members are liable for the difference between the provider’s rate and the NHRPL rate.
Members of medical aid schemes are required to notify and obtain authorisation from their schemes before going into hospital if they are to receive non-life threatening or non-essential hospital treatment. This is known as pre-authorisation.
A pre-existing condition refers to a condition that a prospective member has been diagnosed with, and where treatment has been advised by a medical practitioner, within one year prior to his or her membership application.
Prescribed Minimum Benefits (PMBs)
By law, all medical aid schemes are obligated to provide medical cover for these conditions, as set out in the Regulations of the Medical Schemes Act.
Oncology is the research, diagnosis and treatment of cancer. Different medical aid plans offer different oncology benefits. Oncology treatments include (but are not limited to) radiation therapy, chemotherapy and laser treatment.
Selfmed offers four different medical aid plans, or options, for its members to choose from. Each medical aid option provides different benefits and levels of cover, so our members can choose the plan that best meets their budgets, their needs and the needs of their families.
Out-of-hospital benefits are medical expenses that are incurred on a ‘day-to-day’ basis, such as doctors’ and dentists’ visits. All of our medical aid plans, except for MedXII (which is purely a hospital plan) offer various out-of-hospital benefits.
The reference price is the highest amount that a medical aid scheme will pay for a type of medicine.
Each medical aid member has a unique risk profile and, depending on this profile, a member may be subject to certain underwriting limitations upon joining the scheme. These restrictions may be in the form of waiting periods, exclusions or late joiner penalties.
Roll-over benefits are unexploited medical savings that a medical aid scheme carries over from the previous year, so that a member may take advantage of those benefits in the current year.
Specialists are medical practitioners who offer specialised advice, services or products that are not provided by GPs (general practitioners). Specialists are highly qualified, and are usually called upon to diagnose and treat more complex ailments or conditions.
A tariff shortfall is the difference between what Selfmed pays for a medical service, based on the MSR, and the amount that is charged for that service. For example, if Selfmed covers 80% of physiotherapy treatment, and the physiotherapist charges 100% of MSR, then the member will be responsible for covering the shortfall of 20%. The shortfall can be much larger, as private tariffs vary greatly. Always find out what fees a consultation will attract and negotiate where possible with the healthcare professional, should these fees seem unreasonable to you.
Waiting periods are imposed when a new member joins a medical aid scheme. It could either be a 3-month period during which no claims will be processed, or a 12-month period if the applicant suffers from a pre-existing condition (note that the applicant will be covered for everything except his or her pre-existing condition during this period).