WHAT DO WE MEAN?
We have included a glossary to make the terminology in this member guide easy to understand. Please contact us should you need assistance or require a better understanding of the benefits and what they entail.
Acute medicine
This is medicine that is prescribed for a short period of time to alleviate the symptoms of an acute illness or condition, such as antibiotics for an infection.
Alternative care
This is care approved instead of hospitalisation for services such as wound care upon submission of a treatment plan.
Annual savings limit (ASL)
This is the portion of your monthly contribution that is allocated to a savings account held in the principal member’s name. The money in this account is used to pay for out-of-hospital medical expenses.
Appliance
Devices that are used to benefit or support a patient, it is prescribable such as dressings, mechanical supports, diabetic supplies such insulin pumps, etc.
Beneficiary
A beneficiary is a principal member or a person registered as a dependant of a principal member.
Benefits
Your benefits are the amounts that are available for medical services provided to you or your dependants in terms of the Scheme rules.
Brand-name/Patented medication
Pharmaceutical companies incur high costs for research and development before a product is finally manufactured and released on the market. The company is given a patent to be the sole manufacturer of the specific medication brand for a specified number of years to recover these costs. This medication does not yet have generic equivalents.
Capitation options
Options that provide cost-effective and specified health care coverage at a prescribed network of service providers. These options may be income based and offer access to network providers, e.g. GPs.
Chronic disease list (CDL)
The CDL consists of 26 chronic conditions that are covered by the Scheme in terms of the regulations governing all medical schemes.
Chronic diseases
These are illnesses or conditions requiring medication and/or treatment for prolonged periods of time. The Medical Schemes Act 131 of 1998 provides a list of Prescribed Minimum Benefits (PMBs) that indicate the chronic conditions a medical scheme must cover.
Chronic medication
This refers to medication prescribed by a healthcare provider for a prolonged period of time. It is used for a medical condition that appears on the Scheme’s list of approved chronic conditions according to a medicine formulary.
Claim
A claim is a request for payment following medical treatment that has been provided by a healthcare provider, such as a general practitioner, specialist or hospital.
Consultation
This refers to an appointment with a healthcare provider, such as your general practitioner or specialist, for treatment.
Contribution
Your contribution is the fixed monthly amount that you pay to be registered as a member of the Scheme. Your employer deducts your contribution from your salary or if you are a continuation member, your contribution will be debited directly each month. Remember that you pay your contribution in arrears, this means that at beginning of a month contributions for the previous month are due.
Co-payment
A co-payment is a portion of the cost of treatment or medication for which you are responsible.
Designated service provider (DSP)
This is a healthcare provider or group of providers contracted by the Scheme to provide diagnoses, treatment and care to members in respect of one or more prescribed minimum benefit conditions. This includes doctors, pharmacies and hospitals. When you choose not to use a DSP, you may have to pay a portion of the cost from your own pocket.
Dependant
This is a member’s spouse or partner, who is not a member or a registered dependant of a member of a medical scheme; a dependant child who is not a member or a registered dependant of a member of a medical scheme; a member’s immediate family who is financially dependent of a member of a medical scheme.
Diagnostic treatment pairs (DTP)
A DTP links a specific diagnosis to a treatment and therefore broadly indicates how each of the approximately 270 PMB conditions should be treated.
Exclusions
Exclusions include medical treatment and care not covered by the Scheme.
External prosthesis
Refers to an artificial device that is worn on the outside of the body and is intended to replace or supplement a missing or non-functional body part.
acility fee
Facility fees are the extra costs charged by hospitals to members when they provide services in an outpatient location. For instance, members may be expected to pay a facility fee for consulting a physician in a hospital-operated outpatient facility.
General practitioners (GPs)
GPs are doctors who provide general or primary healthcare services, but do not offer a specialised service.
Generic medicine
This is medicine that has the same chemical ingredients, strength and form (such as a tablet or syrup) as the original, brand-name product. Generic medicine is as safe and effective as the original, brandname product but is usually more cost-effective.
General waiting period
This is a three-month period during which a beneficiary is not entitled to claim any benefits. Internal prosthesis Refers to artificial device that is surgically implanted to replace or support a missing or dysfunctional body part that is intended to stay in permanently or for an extended time.
Late-joiner penalty (LJP)
A LJP is imposed on the contributions of persons joining a medical scheme when they are 35 years of age or older and have not been members of a medical scheme before 1 April 2001 or have had a break in membership exceeding three consecutive months since 1 April 2001.
Moto Health Care (MHC) tariff
This is the rate at which healthcare providers are paid for services rendered to Scheme members.
Medicine formulary
A medicine formulary is a list of cost-effective medicines that guides the doctor in the treatment of specific medical conditions. Medicine formularies are continuously reviewed and updated by medical experts to ensure that they are consistent with the latest treatment guidelines.
Network providers
This is a list of service providers who have been contracted by the Scheme to provide medical care to members at an agreed rate.
Network pharmacy
For acute medicine, use the Scheme’s network of pharmacies. To see if your pharmacy belongs to the network, contact the call centre on 0861 000 300 or visit the Scheme’s website at www.mhcmf.co.za
Network hospitals
The Life Healthcare Group of hospitals is the preferred network of hospitals for the Custom, Classic Network and Hospicare Network options.
Overall annual limit
This limit is the overall maximum benefit that members and their registered dependants are entitled to according to the Scheme rules. This is calculated annually to coincide with the Scheme’s financial year (January to December).
Prescribed minimum benefits (PMBs)
This is a list of conditions that medical schemes have to cover in full according to the Medical Schemes Act.
Pre-authorisation
The confirmation received from the Scheme when a member requires hospitalisation or specialised treatment. Keep in mind that pre-authorisation is not a guarantee of payment but provides confirmation that the member may have access to benefits.
Primary care network
This is a group of healthcare professionals that delivers primary care services, for example, general practitioners, dentists and optometrists. Members on the Custom and Essential options are required to obtain out-of-hospital benefits from these network providers.
Principal member
A principal member is the main member that is registered on the Scheme. POPIA Protection of Personal Information, Act 4 of 2013.
Registered dependant
A registered dependant is a person who is dependent on the principal member and is registered by the Scheme to share in the benefits provided to the principal member.
Sub-limit
This is the maximum amount of money you can claim for a specific service, which is also subject a larger annual amount.
Waiting period
A waiting period is a period during which beneficiaries are restricted from claiming for benefits. This happens when beneficiaries have no previous cover or a break in medical aid cover.
There are two kinds of waiting periods:
- A general waiting period of up to 3 months.
- A condition-specific waiting period of up to 12 months, where pre-existing health conditions are excluded; all medical costs during this period will be the members responsibility.
Wellness benefits
Wellness screening is an important way to detect some medical conditions given.