- Read the material schemes send on the important changes to benefit options for next year.
- If you are unsure, call the scheme to explain any changes, limits, benefits and other relevant information.
- Elect an option according to your healthcare needs and what you can afford.
- You may make use of an agent or broker (intermediary). Remember it is not compulsory to use a broker, but if you do, ensure that he/she has been accredited by the CMS and that your selection of a scheme and benefit option is based on informed consent.
- Medical Schemes may appoint preferred/network providers who have contracts with the Medical Scheme to provide services. The Medical Scheme rules will determine how preferred/network providers are funded. It is as such important that you as the member ensure that you know the scheme rules and study the benefit guide in detail. It is also necessary to contact your Medical Scheme to find out who the preferred provider is before you make appointments.
- Determine how close Designated Service Providers (DSPs) are to your home and/or place of work as well as what co-payments are applicable for the voluntary use of non-designated service providers.
- No restrictions, co-payments, waiting periods or exclusions may be applied to any person in respect of the prescribed minimum benefits (PMBs) if the services are obtained from DSPs. In instances where services are voluntarily obtained from a non-DSP, co-payments may apply.
- Note that pre-authorisation, formularies (approved drugs for a specific medication) and protocols may also be used by a Medical Scheme to ensure that healthcare is cost-effective and affordable.
- Existing Medical Scheme members who wish to move to another scheme should please note that waiting periods may apply. This is a design of the Medical Schemes Act, 131 of 1998 to prevent scheme hopping, where members move from one scheme to another too frequently.
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