Q: How do I choose a medical scheme?
A: Make sure you have the best cover for when you are flat on your back.  Choose the best medical scheme for your specific needs and budget.  Keeping in mind that the industry is complex, you can get expert advice from people who deal with the industry and its complexities on a daily basis.  This service will be to no extra cost to yourself as the scheme administrator will be reimbursing the broker for this service.  (Note that this fee is already included in your contribution, if you use a broker or not.
The following needs to be kept in mind when choosing a medical scheme.

• Make sure the scheme is a registered Medical scheme in terms of the Medical Schemes Act 131 of 1998, and that it is financially sound. The last thing you need when you're lying in the trauma unit is to find out that your medical scheme has gone under. You can check these details on the site of the Council for Medical Schemes.
• Financially sound means:
  • They have a solvency ratio of 25% and more
  • What is the average age of the scheme’s principle members. (The healthier schemes are at averaging 43 years of old)
  • What is the scheme’s non-healthcare cost?
  • What is the total membership of the scheme
• Check things like exclusions and benefits. Remember your membership of a medical scheme constitutes a legal contract, and it is in your best interest to understand the terms of that contract.
• Find out which chronic conditions are covered and what your monthly contributions would be.

Call in the help of an independent broker to help you choose a medical scheme, as they don't have vested interests in any one medical scheme, but will look at several schemes to choose the option that bests suits you and your family.

Q: How do I select the option that's best for me?
A: You can either see a broker, or contact various schemes yourself and ask them to forward you the information. (You can apply directly to them and without using a broker.) Take a look at the benefits they offer – if you have eye problems for example, you won't choose a scheme that only allocates R200 per year for glasses. If you're very healthy, it could be to your advantage to take a scheme with low day-to-day benefits, but good hospital coverage. Read the small print. There are some schemes that look good on paper, as it seems that they pay 100% of claims, but take note of that 100%.   Is it perhaps only 100% of the NRPL tariff and do they have overall limits?  Assess your needs carefully and choose the option that will give you the best coverage for your needs.

Q: Can anyone become a member of a medical scheme?
A: Yes. Medical schemes used to be able to reject applications from old / sick applicants because they would be a high risk to the scheme.  In terms of the Medial Schemes Act 131 of 1998, all applications must be accepted since 01/2000.  The scheme may exclude treatment for a specific illness condition for a maximum time period of 12 months, depending on your previous medical scheme history. They may also impose a three month general waiting period, depending on your previous medical scheme history. Should a person apply at a late stage in his / her life, the scheme may increase the contribution, also depending on their previous medical scheme history and depending on their age at application.  Some schemes are not open to the general public and are restricted to a company’s employees, profession or union.  These schemes are called closed schemes.

Q: What is a co-payment?
A: Medical schemes seldom cover 100% of any medical bills. A co-payment is the portion of the bill for which you are responsible. If your medical scheme pays 100% of the NRPL tariff and your doctor charges more than the NRPL tariff, you will be liable for the difference.  For Example: Your account is for R3 500, but the NRPL tariff, might only be R2 500.  The scheme will then pay R2500 and you will be liable for the difference on R1 000.
Some schemes specify certain hospital procedures where you have to pay something towards the hospital account.  This can very from R1 000 to R5 900.

Q: What are Day-to-Day services?
A: Day-to-Day services are all medical services where the member is not hospitalised. This will includes your spectacles, medication, doctors’ visits, specialist visits etc.

Q: What are limits?
A: These are limits, either overall or in categories, which are the maximum that a member and his dependants can spend in a particular year for out-of-hospital expenses. Schemes work according to a financial year, 01 January to the end of December. These categories usually include things such as visits to the doctor, prescribed medication, glasses or contact lenses, specialists, physiotherapists and so forth.
On low-cost medical schemes these day-to-day limits are often not very high, but the hospital cover is quite sufficient. This is how that particular option within a medical scheme can afford to keep the monthly contributions low. On some options within a medical scheme, the day-to-day limits could be high, but this will then be reflected in the higher monthly contribution. If a medical scheme covers 80% of the NRPL rate of a visit to the GP, the remainder of 20% will have to be paid by the member. If the GP charges more than NRPL rate, the difference will be for the member's own account.

Q: What is a medical savings account?
A: This is a fixed amount of money that a medical scheme member put in a savings account on a monthly basis.  It forms part of his contribution. On some options, this money is used to pay the services that are not done whilst hospitalised and on some options, this will be an additional benefit. Any positive money in your Savings account at the end of the year,  can be carried over from year to year. You will therefore never loose the positive savings in your Savings account.  Should you leave that particular scheme the positive savings will be transferred to the new scheme after 4 months. (According to legislation you have 4 months to submit accounts after service date.)

Q: Can one person belong to more than one medical scheme?
A: No, that is not legal. Double claims for the same medical expenses are fraudulent.

Q: What does NHRPL stand for?
A: National Health Reference price Listing.
This is the guideline price published by the Department of Health for all medical services.
Your doctor may or may not charge according to the price listing.  According to the Competition’s Commission, he is not bound by this price listing.

Q: Who qualifies as a dependant on a medical scheme?
A: In terms of the Medical Schemes Act, no medical scheme may refuse to admit persons who are dependent on the member. Dependants of a member is his/her spouse or partner; children under the age of 21, or children older than age 21 dependent upon the member due to a mental or physical disability, or still financially dependant on the member; immediate family in respect of whom the member is legally liable for family care and support, and such other persons who are recognised by the scheme as dependants. Immediate family is classified as the mother or father of the member. The scheme concerned may require proof of such financial dependency and appropriate additional contributions in respect of such extended cover must be expected.
You may not register family members over 21 who are not financially dependant on you.

Q: Can I put my ex-spouse on my medical scheme?
A: If a court awards medical benefits to your spouse in a divorce case, you can keep your ex-spouse on your medical scheme. Should you get married again, your new spouse can also join your medical scheme. Any children, including stepchildren or adopted children who are your dependants, can join your medical scheme.

Q: Does my employer have to subsidise my contributions to the medical scheme?
A: No, employers do not have to subsidise contributions of their employees to medical schemes, although there are many employers who do this, especially if the scheme is an in-house scheme.

Q: If I resign from the scheme, until when can I claim?
A: You can submit claims for medical treatment up until the day your medical scheme membership expires. If you gave written notice of your intention to end your membership on the 31st of December, and you go to the doctor on that day, you can still submit a claim for that doctor's visit. Anything after that date will not be processed. There are scheme’s however that requires a three month termination period.  In such a case your will be paying contributions for those last three months, and you will also be able to claim for services rendered during these three months.

Q: Can a medical scheme terminate my membership?
A: Yes, if you belong to a closed scheme and you are retrenched or made redundant or you resign form the company.
An open scheme can only terminate someone's membership if they do not pay their contributions or if fraud has taken place.

Q: How are medical scheme contributions determined?
A: There are basically four things:

• Your income (in some cases)
• The cover you require (full cover or just hospital cover)
• The number of people you want to register on the scheme
• Previous medical scheme history

Q: What is a DSP (designated service provider)?
A: A Primary healthcare provider or group of providers who deals with your family’s day-to-day basic healthcare needs or deals with the diagnosis, treatment and care in respect of one or more prescribed minimum benefit condition.

Q: What are prescribed minimum benefits (PMBs)?
A: The benefits in respect of relevant health services prescribed by the regulations under the Act, and rendered by State hospitals or designated service providers according to clinical protocols and criteria. No restrictions, co-payments, waiting periods or exclusions may be applied to any person in respect of the prescribed minimum benefits if the services are rendered by State hospitals or DSP’s.
In instances where services are voluntarily obtained from a non–DSP, co–payments may apply or waiting periods may be imposed only on those applicants who have never belonged to a medical scheme, or have not been beneficiaries for the preceding 90 days.

Q: May a medical scheme refuse to admit my dependant?
A: No, in terms of the Medical Schemes Act, no medical scheme may refuse to admit persons who are dependent on the member. Dependants of a member are his/her spouse or partner; a child under the age of 21; a child over age 21 dependent upon the member due to a mental or physical disability or being financially dependant; immediate family in respect of whom the member is legally liable for family care and support and such other persons who are recognized by the scheme as dependants. Immediate family is classified as the mother or father of the member. The scheme concerned may require proof of such financially dependency and appropriate additional contributions in respect of such extended cover must be expected.

Q: If a member dies, will his registered dependants still be covered?
A: Yes, without any break in membership and provided contributions are paid. It is important to inform the scheme if one chooses not to continue.

Q: Can you still claim if you have given notice to leave the scheme?
A: Yes, you are still covered until the last day of your notice period. Claims after that date will not be processed. Most schemes require a month or more written notice of your intention to leave the scheme.