WHAT DO WE MEAN?

We have included a glossary to make the terminology in the benefit descriptions easy to understand. Please contact us should you need assistance or require a better understanding of the benefits and what they entail.

Annual savings limit
This is the portion of your monthly contribution that is allocated to a savings account that is held in the principal member’s name. The money in this account is used to pay for out-of-hospital medical expenses.

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.

Beneficiary
A beneficiary is a principal member or a person registered as a dependant of a member.

Benefits
Your benefits are the amounts that are payable for medical services provided to you or your dependants in terms of the Scheme Rules.

Benefit limits
Your benefits are the amounts that are payable 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 the patent to be the sole manufacturer of the specific medication brand for a number of years to recover these costs. This medication does not yet have generic equivalents.

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 for prolonged periods of time. The Medical Schemes Act 131 of 1998 provides a list of prescribed minimum benefits that indicates the minimum 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.

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, specialist or physiotherapist for treatment.

Contribution
Your contribution is the fixed monthly amount that you pay to be registered as a member of the Scheme.

Co-payment
A co-payment is a portion of the cost of treatment or medication for which you are responsible, usually to pay for a portion of the cost of care that is not covered by a medical scheme.

Designated service provider (DSP)
This is a healthcare provider or group of providers chosen 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 of the consultation or treatment from your own pocket.

Disease Treatment Pair (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 that are not covered by the Scheme.

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, brand-name product but is usually more cost-effective.

General waiting period
This is a period during which a beneficiary is not entitled to claim any benefits. This is normally a 3-month period.

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 had 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 will be paid for services rendered to Scheme members.

Medicine formulary
A formulary is a preferred list of prescription medicine that is covered by the Scheme.

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.motohealthcare.org.za.

Network hospitals
The Life Healthcare Group of hospitals is the preferred network of hospitals for the Custom, Classic Network and Hospicare Network options.

Non-Chronic Disease List
These are additional diseases that we cover over and above the
26 chronic conditions.

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.

Prescribed minimum benefits
This is a list of conditions that medical schemes have to cover in full according to the Medical Schemes Act.

Preventative care benefits
This is treatment that is given to prevent or reduce the risk of developing a medical condition.

Pre-authorisation
Pre-authorisation is the process of informing the Scheme of a planned procedure so that cover for the procedure can be assessed. Keep in mind that pre-authorisation is not a guarantee of payment.

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 healthcare providers.

Preferred provider
See network providers.

Principal member
A principal member is the main Member that is registered on the Scheme.

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.

Scheme rate
This rate is the price agreed upon by the Scheme and healthcare service providers for the payment of services that are provided to members of the Scheme.

Shared limit or sublimit
This is a benefit that applies to 2 or more benefit categories. An example is the general dentistry limit and the day-to-day limit on the Optimum option. If members have used the full day-to-day limit, the general dentistry limit will also be depleted. If members use the general dentistry limit, they may still have day-to-day limits, but these
will be reduced by what was spent on the general dentistry limit.

Specialists
Specialists are doctors who have specialised in a particular medical field, such as oncology, paediatrics or gynaecology.

Waiting period
A waiting period is a period during which contributions are payable, but where the member is not entitled to benefits.

There are two kinds of waiting periods:
a) a general waiting period of up to 3months
b) 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 member’s responsibility.