An acute condition is a self-limiting condition which disappears after treatment e.g. appendicitis and tonsillitis.
The healthcare model whereby a fixed amount of money is paid by a managed care organisation to a network of healthcare providers. The opposite of a capitation model is a fee-for-service model.
Chronic Condition or Illness
A chronic illness is a life-threatening condition that requires ongoing treatment e.g. diabetes and asthma.p>
Medication that is taken for a chronic condition. Medical schemes are entitled to manage the benefits for these conditions by specifying your choice of medication. Cover can be limited to certain brands or generic medication.
Claims Paying Ability
This is the number of monthly claims that the scheme is able to cover with its existing cash and cash equivalents.
In terms of legislation, all members of a medical scheme option must pay the same contributions and cannot be asked to pay more due to age or ill health.
Principal members of restricted medical schemes are entitled to remain on the scheme after retirement even if the employer no longer pays the contribution. In the event of the death of the principal member, the dependants will still be covered by the scheme.
A co-payment is a portion of the bill for which the member is responsible. Some options have co-payments for certain procedures meaning that the member needs to pay the designated amount when receiving treatment for that particular procedure. The term co-payment can also be used to describe the member’s portion of the bill if the scheme/option only covers treatment at a certain % and the provider charges above that %.
A set rand amount that must be paid upfront by the member for a defined list of procedures.
Designated Service Provider
A group of medical service providers specified in the fund rules from whom services must be obtained to enjoy appropriate treatment and lower or no co-payments.
Some medical conditions and procedures may be excluded from medical schemes e.g. cosmetic surgery and self-inflicted injuries.
Late Joiner Penalty
The Medical Schemes Act makes provision for schemes to apply a late joiner penalty to members over the age of 35. Depending on the number of years that you have not belonged to a registered South African medical scheme over the age of 21, the late joiner penalty is calculated as a percentage of your monthly contribution and will be added to your monthly contribution.
These are options that are in most cases income based, making them affordable for the individual earning a lower income. The medical aid scheme designates certain hospitals, doctors, chronic providers and dentists. The member must make use of these designated providers in order for treatment to be covered by the scheme.
Hospital admissions for non-essential or non-life threatening procedures need to be authorised by the medical scheme prior to the member being admitted.
A condition for which a member has received medical advice, diagnosis, care or treatment was recommended within 12 months prior to application for membership to a medical scheme.
Prescribed Minimum Benefits
This is a list of 270 treatments plus 26 chronic diseases, for which all medical aid schemes in South Africa have to provide cover in terms of the Medical Schemes Act.
Unused medical savings that are carried over from one year to the next.
Depending on a new member's risk profile, they are sometimes subject to underwriting limitations. Restrictions can take the form of late-joiner penalties, waiting periods or exclusions.
Medical practitioners who offer specialised products or services not offered by general practitioners (GPs) are called medical specialists. A specialist is more qualified to give an accurate diagnosis of a complex condition.
When a member joins a medical scheme two types of waiting periods can be imposed: a three month general waiting period during which no claims will be paid, and/or twelve month pre-existing condition exclusions.