FREQUENTLY ASKED QUESTIONS ABOUT MEDICAL SCHEMES AND THE INDUSTRY

These are limits, either overall or in categories, which are the maximum that a member and his dependants can spend in a particular year for out-of-hospital expenses. Schemes work according to a financial year, 01 January to the end of December. These categories usually include things such as visits to the doctor, prescribed medication, glasses or contact lenses, specialists, physiotherapists etc. On low-cost medical schemes these day-to-day limits are often not high, but the hospital cover is quite sufficient. This is how that particular option within a medical scheme can afford to keep the monthly contributions low. On some options within a medical scheme, the day-to-day limits could be high, but this will then be reflected in the higher monthly contribution. If a medical scheme covers 80% of the NRPL rate of a visit to the GP, the remaining 20% will have to be paid by the member. If the GP charges more than NRPL rate, the additional difference will be for the member's own account.

Day-to-Day services are all medical services where the member is not hospitalised. This will include your glasses, medication, doctors’ visits, specialist visits etc.

A member is entitled on request, to copies of the scheme's rules, financial statements, and annual reports upon payment of a reasonable fee for such documents. On admission to membership medical schemes are obliged to furnish members with a summary of the registered rules which comprise reciprocal rights and obligations of both the scheme and members and all benefit options and relevant contributions.

The Medical Schemes Act 1998 (Act 131 of 1998) came into operation on 1 February 1999. Regulations were introduced by Government Gazette No 20556 dated 20 October 1999, with effect from 1 November 1999 and 1 January 2000 respectively.

Ensure that you understand how the benefit options operate and elect according to your healthcare needs and what you can afford. The registered rules of medical schemes fully disclose detailed information regarding the relevant benefits and contributions. It is essential that you obtain the rules of the scheme or a summary thereof to verify all information relevant to enable you to make an informed choice.

Instead of changing schemes and be faced with waiting periods, a member can either buy up in order to get better benefits or buy down for less contributions.

Yes, except in an emergency where pre-authorisation should be obtained as stipulated in the rules.

No, in terms of the Act a medical scheme must give members advance written notice of any change in contributions and benefits or any other condition affecting their membership.

No, the Act prohibits the payment of bonuses, rebates or re-funding of any portion of contributions other than in respect of savings accounts in certain circumstances.

No, contributions may only be based on a member's income and/or the number of his dependants or both. The contributions apply universally to all members who are enrolled and their dependants.

Yes, unless proof of a reduced income is submitted to the Scheme.

No, contributions to a medical scheme may only be based upon a member's income and/or his number of dependants.

Closed scheme - in case of 1 and 2 - Yes and 3 - No, Open scheme - No, you simply continue your membership provided contributions are paid.

Yes, since the employer pays the contributions on behalf of its employees and since the scheme has a contract with the member. The Scheme must give the employer and or/member written notice that if the contributions are not paid up within the stipulated period in the rules membership may be cancelled.

The employer may determine whether or not the employees are entitled to belong to one or more schemes or whether the employees have total freedom of choice of scheme. The employer also determines, generally within the framework of conditions of service, negotiations between the workforce and organized labour, such as trade unions/personnel organizations or staff, what level of subsidies will apply to different categories of employees or in general. Therefore, employers are not admitted to membership but they play an important role in collecting contributions and ensure payment thereof to the scheme concerned.

No, subsidies are conditions of employment and the Act does not address such conditions.

Yes, until the last day of membership provided contributions are being paid.

Yes, the notice period stipulated in the rules must be complied with.

Yes, without any break in membership and provided contributions are paid. It is important to inform the scheme if one chooses not to continue.

If a court awards medical benefits to your spouse in a divorce case, you can keep your ex-spouse on your medical scheme. Should you get married again, your new spouse can also join your medical scheme. Any children, including stepchildren or adopted children who are your dependants, can join your medical scheme.

No, there is no such provision in the Act. One can apply directly to the scheme or opt to use the services of a broker (intermediary).

No, in terms of the Medical Schemes Act, no medical scheme may refuse to admit persons who are dependent on the member. Dependants of a member are his/her spouse or partner, child under the age of 21 or older and a child who is dependent upon the member due to a mental or physical disability; immediate family in respect of whom the member is legally liable for family care and support and such other persons who are recognized by the scheme as dependants. Immediate family is classified as the mother, father, brother or sister of the member. The scheme concerned may require proof of such dependency and appropriate additional contributions in respect of such extended cover must be expected.5

In terms of the Medical Schemes Act, no medical scheme may refuse to admit persons who are dependent on the member. Dependants of a member are his/her spouse or partner; children under the age of 21, or children older than age 21 dependent upon the member due to a mental or physical disability, or still financially dependent on the member; immediate family in respect of whom the member is legally liable for family care and support, and such other persons who are recognised by the scheme as dependants. Immediate family is classified as the mother or father of the member. The scheme concerned may require proof of such financial dependency and appropriate additional contributions in respect of such extended cover must be expected. You may not register family members over 21 who are not financially dependent on you.

Yes, with the assistance of his/her parents or guardian, provided that the relevant contributions are paid by him/her or on behalf of him/her.

No. It is illegal.

Yes, except in a restricted membership scheme, for instance, where a particular employer, profession, trade, industry, calling, association or union has established a scheme exclusively for its employees or members.

It is a portion of the cost for which you are responsible.

Yes, in those instances where the person was a beneficiary of a medical scheme for up to 24 months.

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.

A scheme must within 30 days of termination of membership, or at any time at the request of a former member, or of a dependant of a member, provide such person with a membership certificate stating the period of cover and other prescribed information. The applicant is also entitled to produce a sworn affidavit in those instances where reasonable efforts to obtain documentary evidence of previous membership were unsuccessful.

Waiting periods do not apply in respect of:

1. Prescribed minimum benefits other than specified in Q28
2. A child dependant born during the period of membership
3. A member moving between benefit options unless he has to complete the remaining period of previously imposed waiting periods.
4. When an individual has to involuntarily transfer to another scheme due to a change of employment.
5. In instances where an employer changes the medical scheme of hisemployees with effect from the beginning of the financial year.

A period during which contributions are payable without the member being entitled to benefits.

There are two kinds of waiting periods i.e.:

1. General waiting period of up to three months.
2. Condition-specific waiting period of up to 12 months.

Involuntary obtained means:

1. the service was not available from the designated service provider or would not be provided without unreasonable delay;
2. immediate medical or surgical treatment for prescribed minimum benefit condition was required under circumstances or at locations which reasonably precluded the beneficiary from obtaining such treatment from a designated service provider; or
3. There was no designated service provider within reasonable proximity to the beneficiary's ordinary place of business or personal residence.

 

No restrictions, co-payments, waiting periods or exclusions may be applied to any person in respect of the prescribed minimum benefits if the services are rendered by State hospitals or DSPs. In instances where services are voluntarily obtained from a non-DSP, co-payments may apply or waiting periods may be imposed only on those applicants who have never belonged to a medical scheme, or have not been beneficiaries for the preceding 90 days.

A healthcare provider or group of providers selected by the scheme as the preferred provider or providers to provide to its members diagnosis, treatment and care in respect of one or more prescribed minimumbenefit conditions.

The benefits in respect of relevant health services prescribed by the regulations under the Act, and rendered by State hospitals or designated service provider according to clinical protocols and criteria.

No, there is no such provision.

In the form of an affidavit directed to the Council and furnished to the Registrar of Medical Schemes not later than three months after the decision concerned was made by the disputes committee.

You can lodge an appeal with the Appeal Board and only at this stage a prescribed fee will be payable.

Apart from your rights to the courts, you  may appeal to the Council for Medical Schemes against such decision. The parties concerned may appear before Council in person or through a representative. Legal representation is not obligatory.

No, there is no such provision.

Any complaint must first be lodged with the scheme concerned. Written complaints would certainly be preferable, but all schemes should also have dedicated telephone lines to handle everyday complaints and enquiries. All schemes are also required to have independent disputes committees where members' disputes may be settled. Members and or their legal representatives may be present at disputes committee meetings to present their arguments. Legal representation is not obligatory. Should all efforts fail to resolve an issue with your scheme, you can submit your complaint to the Council for medical Schemes Complaints Unit by either posting, faxing, emailing or submit online by going to the following website address: http://www.medicalschemes.com/Consumer_Assistance/CMain .

Yes. Health care providers are free to determine their own fees. Consequently, if an account is in excess of the fee determined by the rules of a medical scheme/NHRPL for a particular service, the difference is for the account of the member.

This is a price list for health services published by Council for Medical Schemes and is used to reimburse service providers.

It is a discretionary benefit which a medical scheme may consider, normally when the member suffers undue hardship. Schemes are not obliged to make provision therefor in the rules and members have no statutory right thereto.

If the account or claim is correct and acceptable for payment, it should be paid within 30 days of receipt of the claim.

Payment of claims is regulated by the Act, which includes the dispatch to a member of a statement containing full particulars of the transaction, including the amount charged for every service and the amount of the benefit awarded for each service.

No, the Act specifically prohibits it.

No, except on termination of membership. Funds in the MSA may be used by the scheme to offset any debt owed by the member which would include contributions.

Only when you terminate your membership of the scheme or a benefit option, without joining another medical scheme or benefit option with a savings component.

The account must be submitted not later than the last day of the fourth month following the month in which the service was rendered.

This is a fixed amount of money that a medical scheme member puts in a savings account on a monthly basis, as part of their medical aid contribution. On some options, this money is used to pay the services that are not done whilst hospitalised and on other options, this will be an additional benefit. Any positive money in your savings account at the end of the year is carried over from year to year. You will therefore never lose the money in your savings account. Should you leave that particular scheme, the positive savings will be transferred to the new scheme after 4 months. (According to legislation you have 4 months to submit accounts after service date.) [See MSA]

Yes, there is provision in the Act and in the rules of every medical scheme on how the Board of Trustees may amend rules. All rule amendments must however be approved and registered by the Registrar of Medical Schemes as required by the Act. The scheme will still notify members of such changes as they entitled to it.

No, in terms of the Act, such reserves are assets of that scheme and all moneys and assets belonging to a scheme must be kept by that scheme.

In terms of the Act a medical scheme must at all times have assets to cover its liabilities. Furthermore, a scheme must, over a period of time, hold surplus or accumulated funds equal to at least 25% of gross annual contributions to ensure financial stability.

Certain stated benefit type insurance products, like hospital plans, where the benefit is not coupled to a healthcare service and/or the cost of such service, are not controlled by the Medical Schemes Act. They fall under the jurisdiction of the Financial Services Board (FSB).

Yes, in terms of the Act, a medical scheme must provide for annual general meetings (AGMs) where members may voice their views and present motions. Medical schemes may also hold meetings at different venues for the benefit of members or provide for regional meetings to maximize member participation.

Contributions are pooled for the benefit of members. Schemes are not-for-profit organizations and belong to the members. Therefore, any surplus made remains in the scheme on the trust principle, for the benefit of members and their dependants.

Board of Trustees of which at least 50% must be elected or appointed from the ranks of members. These persons must be fit and proper to perform their duties, ensure that the interests of members are protected and that the scheme is properly administered. If they are guilty of misconduct, or reckless trading, they may be held accountable for losses incurred.

Only on the grounds of failure to pay membership fees timeously or other debts owing to the scheme, submission of fraudulent claims, committing other fraudulent acts, or the non-disclosure of material information.