10 April 2012

Dictionary of terms

Easy-to-understand explanations of medical scheme and hospital plan terms, jargon and abbreviations.

Easy-to-understand explanations of medical scheme (aka medical aid) terms, jargon and abbreviations.

Acute medicine
This is medicine used for diseases or conditions that have a rapid onset, severe symptoms, and that require a short course of medicine treatment. It can also mean medicines that you can claim for, but have not been classified as chronic medicine by your scheme.

A dependant who is 21 years or older.

Agreed tariff
Sometimes a fund has agreements with preferred providers, such as doctors and/or hospitals, where specific tariffs have been negotiated.

Ambulance services
This includes all medically equipped transport like ambulances or helicopters utilized for a medical emergencies.

Application date
It is the actual date on which the scheme receives an application for membership or registration of a dependant.

AT (Agreed Tariff)
Your medical scheme might have agreements with DSP’s (Designated Service Providers) / Preferred Service Providers. The AT is the tariff that the involved parties agreed upon.

Every individual member and dependant who receives benefits from the scheme.

These are all the things you can expect from your specific medical scheme, or all the medical costs that they are covering for you.

Branded/patented medicine
Pharmaceutical companies incur high costs for research and development before a product is finally manufactured and released into the market. To recover these costs, the company is given the patent right to be the only manufacturer of the specific medicine brand for a number of years.

Cancer treatment
[See "Oncology"]

Chronic diseases
These are illnesses or diseases requiring medicine for an uninterrupted period of more than three months. The Medical Schemes Act provides a PMB (Prescribed Minimum Benefit) listing the minimum chronic conditions your medical scheme should cover under law. With reference to this list, your medical scheme compiles its own list of approved chronic diseases that it will cover – for example high blood pressure, diabetes or cholesterol.

[See "Chronic medicine" and "Chronic medicine benefit"]

Chronic medicine
This is medicine prescribed by a medical practitioner for an uninterrupted period of at least three months. This medicine is used for a medical condition that appears on your scheme’s list of approved chronic conditions. [See "Chronic diseases” and “Chronic medicine benefit"]

Chronic medicine benefit
This is a medical scheme benefit that covers medicine for a specified list of conditions. This can vary according to the medical scheme option that you chose. [See "Chronic diseases” and “Chronic medicine"]

After you’ve received medical treatment, you or the service provider (the doctor or hospital) submits a claim to your medical scheme to request payment of the bill. Usually you can wait for your scheme to pay out the claim, or you can pay the bill from your own pocket and then claim the amount back from your scheme.

Commencement date
[See "Inception date"]

This refers to your visit to your service provider, like your doctor, specialist, physiotherapist, etc.

That is the fixed amount that you are paying monthly to be a member of your medical scheme. You pay a fixed amount for each adult dependant and each minor dependant that is registered under your membership.

Medical schemes seldom cover 100% of medical bills. A co-payment is the portion of the bill for which you are responsible.

Day-to-day limits
You and your dependants can spend a certain maximum amount of money in a particular year for out-of-hospital expenses. These day-to-day limits can be calculated for overall expenses or expenses that fall into certain categories. [See "Threshold"]

Dental benefits
Depending on the medical scheme option you chose, you can have dental benefits, which can include a wide range of different dental treatments and procedures.

These are registered persons that the main member is supporting and who are not members or dependants of any other scheme. It can be a spouse, parents, sisters, brothers, and own, adopted, step or foster children as well as any other person approved by the scheme.

Disease management
It’s a holistic approach that focuses on the patient’s disease or condition, using all the cost elements involved. It can include patient counseling and education, behavior modification, therapeutic guidelines, incentives and penalties and case management. The beneficiary usually has to co-operate with the program in order to receive the benefits.

DSP (Designated Service Provider)
Your scheme negotiated preferential rates with this specific service provider in offering you benefits for PMB (Prescribed Minimum Benefits) conditions. These are, for example, specific doctors, specialists, hospitals or pharmacies that your medical scheme wants you to use.

Effective date
[See "Inception date"]


[See "Waiting period (condition specific)"]

This is a medical scheme member and his/her dependants.

It’s a defined list of medicine used to treat various diseases. There are different formularies for different diseases.

Generic medicine
Generics are medicines that contain exactly the same active ingredients as their branded equivalents. The same or another company manufactures these medicines when the patent on the branded product expires. As a result, these medicines are usually much cheaper.

This is a high-cost specialty chronic medicine used in some cases to treat breast cancer [Link to "History on the Herceptin/breast cancer war"]

The Human Immunodeficiency Virus is a retrovirus that breaks down the human body’s immune system and can cause Acquired Immunodeficiency Syndrome (AIDS). AIDS is a condition where the immune system begins to fail, leading to life-threatening opportunistic infections.

Hospital plan
If you only need medical cover for hospitalization and not for day-to-day medical expenses, you can join a hospital plan. You can either get a hospital plan from a medical scheme or you can take out hospital cover from an insurance company.

ICD codes
The inclusion of ICD 10 codes on claims from healthcare providers to medical schemes is a mandatory requirement since 1 January 2005. Every medical condition and diagnosis has a specific code, called the ICD 10 code. These codes are used primarily to enable medical schemes to accurately identify the conditions for which you sought healthcare services. This coding system then ensures that your claims for specific illnesses are paid out of the correct benefit and that healthcare providers are appropriately reimbursed for the services they rendered. It stands for "International Classification of Diseases and related problems".

Inception date
This is the date on which you become a member of a scheme and your dependants’ membership is registered. Your premiums are payable from this date.

Late joiner
If you’re 35 or older and haven't been a member of a medical scheme for the last two years, you will be seen as a late joiner when you apply for membership or registration as a dependant on a medical scheme. Your medical scheme may charge you with a "late joiner penalty", increasing your monthly contributions in accordance with the stipulations of the Medical Schemes Act.

Major medical benefits
That includes all the benefits for services you are insured for, like hospitalization, procedures and treatment you can receive while in hospital.

Managed healthcare
This is any effort to promote the rational, cost-effective and appropriate use of healthcare resources. Usually members only qualify for benefits if they have followed the guidelines and protocols the medical scheme has set out to manage the illness. Example: In the case of oncology treatment, managed healthcare would probably mean that you’d have to join a case management programme. Your doctors and specialists and the specialists from your medical scheme will work together to decide on the most cost effective treatment programme. [Link to "History of managed healthcare"]

Medical insurance
[See "Hospital Plan"]

This is any person who has been registered as a member by a scheme – including main members and dependants.

This is a dependant who is not yet 21 years old. Some schemes also include older students as "minors".

MMAP (Maximum Medical Aid Price)
This is the maximum medical aid price that your scheme will pay for the cost of generic medicine, where a generic alternative for branded medicine does exist. Only the cost of the generic equivalent is covered.

MSA (Medical Savings Account)
You can have a medical savings account at your scheme to which you contribute monthly. When you need day-to-day medical services or supplies, you can pay these from this account.

When your scheme has negotiated preferential rates with a specific service provider in offering you your benefits, the list of preferred providers is called the "network". You will most probably be limited to use the suppliers (like doctors, pharmacies, hospitals) that are registered with this network of providers. [See "Designated Service Provider (DSP)"]

NHRPL (National Health Reference Price List)
The Department of Health publishes these tariffs and rules for specific health services or supplies. Medical schemes are obliged to follow these rules and tariffs. [See "BHF rates" and "SAMA rates"]

Non-prescribed medicine
[See "Pharmacist Advised Therapy (PAT)"]

This field of medicine is included in the treatment of cancer. It can consist of chemotherapy and radiation therapy. If you’re a member of a medical scheme, you will probably have to join a disease management programme, of which your oncology treatment will form a part.

Optical benefits
Depending on the medical scheme option you chose, you can have optical benefits, which can include a wide range of optical treatments and supplies, like eye examinations, spectacles and contact lenses.

These are the different products registered by medical schemes, offering members sets of specific benefits.

PAR (pre-authorisation)
This is when you need to get approval before any planned admission to a hospital. Your scheme will supply you with prior approval in the form of a pre-authorisation number.

PAT (Pharmacist Advised Therapy)
Most common ailments can be treated effectively by medicines available from your pharmacy without a doctor’s prescription. If your medical scheme option offers you a PAT benefit, it means that some of these costs will be paid for by your medical scheme.

PMB (Prescribed Minimum Benefits)
The Medical Schemes Act lays down the minimum benefits that you should receive from your medical scheme.

Preferred provider
[See "Designated Service Provider (DSP)"]

Primary Healthcare Provider
A primary healthcare provider deals with you and your family’s day-to-day healthcare needs – like treating a minor burn. These can include general practitioners (GP's) and nurses.

Private hospital
Unlike state hospitals, private hospital groups are run as businesses and cost a whole lot more. Although some state facilities are excellent, private hospitals usually offer more luxury and better aftercare. If you're a member of a medical scheme, you will probably receive healthcare in a private hospital.

Pro-rata benefits
Some of your medical scheme benefits are given on a calendar year basis, which means that you have an annual limit on them. If you join a scheme on a date other than 1 January, your benefits are calculated pro-rata, which means that you receive a year’s benefits in advance. If you exceed your annual limit, you’ll have to pay excess costs out of your own pocket.

In some cases, your monthly contributions to your medical scheme will be split into two portions – a risk and a savings portion. The risk portion reflects your contribution to benefits that are being paid by the scheme and not from a savings component.

Risk underwriting
When a scheme looks at the application of a group, they will require certain information from the company in order to see what the risk to the scheme will be. Risk factors include the average age of the employees, the pensioner ratio as well as the number of chronic medicine users within the group. Once this information has been established, the scheme can decide what underwriting will be applied to the group with regards to new applicants. [See "Underwriting"]

SAMA rates (South African Medical Association)
This is the tariff structure that the South African Medical Association deems to be appropriate for their members (doctors and specialists). It is a guideline for doctors in private practice regarding what fees they may charge for their services.
[See "BHF rates" and "NHRPL"]
Medical scheme tariff structures

Self-payment gap
When your scheme benefits or medical savings account is depleted, there will be a period during which you will have to fund a certain portion of your claims from your own pocket.

Service date
This can be the date on which you are discharged from hospital, the date you have received a medical service or medical supplies, or the date that you terminate your membership.

Service provider
This is anyone who gives you medical advice and service, like your doctor, dentist, pharmacist, nurse, medical auxiliary or hospital.

For specialized medical treatment that cannot be offered by your general practitioner (GP), you can receive care from a wide range of specialists, including internists, cardiologists, urologists, gynecologists, pathologists, a wide range of surgeons and in the case of an operation, anesthetists.

The person you are married to under any law or custom that is recognized by South African law.

Start date
[See "Inception date"]

State hospital
This is the system of hospitals of each provincial government in South Africa. These can include training hospitals where nurses, doctors, specialists and other medical professionals are trained. If your local state hospital does not offer specialist treatment of a disease, your state health service provides any necessary transfer to other state hospitals outside your province of residence where you can obtain the necessary treatment.

The Bill
It refers to the Medical Schemes Act of 1998. This act stipulates your rights as a medical scheme member. The Bill and the regulations thereunder are amended or replaced from time to time.

On some medical scheme options, you pay for your day-to-day medical expenses from your medical savings account or from your own pocket, until your claims reach a certain limit. Once your day-to-day expenses have reached that fixed rand amount, for example, R5 000, (your "threshold"), your medical scheme kicks in and will pay further claims up to a certain limit.

Depending on your previous medical scheme history, your new medical scheme can apply underwriting on your new membership. This means that according to regulation, they are allowed to impose a three-month general waiting period and/or a twelve-month waiting period on an existing illness condition. A Late Joiner Penalty can also be placed. [See "Waiting period (condition specific)", "Waiting period (general)" and "Late joiner"]

Waiting period (condition specific)
Depending on your previous medical scheme history, a scheme may impose a waiting period of up to 12 months from the inception date of your membership, for any pre-existing conditions. No benefits will be paid out for any costs involved in this condition.

Waiting period (general)
Your scheme will probably have a three-month general waiting period on benefits for new members. No benefits are paid out during this period, not even from a MSA (medical savings account), except for some procedures that are covered within the PMS (Prescribed Minimum Benefit) as prescribed by the Medical Schemes Act.

How to choose the right medical scheme

(Health24 , updated February 2011)


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