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HEALTH
CARE COVER: NEW DISPENSATION UNDER THE MEDICAL SCHEME ACT 131, 1998 (THE ACT)
QUESTIONS
ASKED MOST FREQUENTLY
CATEGORY:
GENERAL INFORMATION
Q1
When did the medical Schemes Act
come into operation?
Q2
How
may a member ascertain what his obligations to the scheme are
and what his rights, benefits contributions and limitations or
benefits are from time to time?
CATEGORY:
SELECTION OF SCHEME AND BENEFIT
PLANS/OPTIONS
Q3
How do I as an individual select an appropriate medical
scheme?
Q4
How do I know which benefit option to select?
CATEGORY:
MEMBERSHIP, CONTRIBUTIONS & BENEFITS
Q5
What is a co-payment?
Q6
Is membership of a medical scheme available to any
person?
Q7
Can I belong to more than one Medical Scheme at the
same time?
Q8
Can
a minor become a member?
Q9
May a medical scheme refuse to admit my dependant?
Q10
Must a prospective member apply for membership of a
medical scheme through a broker?
Q11
If a member dies, will his/her dependants still be
covered?
Q12
Must I give notice to the scheme in the event that I
wish to terminate membership?
Q13
Am I
entitled to benefits while serving notice of
termination?
Q14
Must my employer subsidize my
contribution to the medical scheme?
Q15
What
role does my employer play in my relationship with my
scheme?
Q16
Is
my scheme entitled to cancel my membership when the employer
fails to pay the membership fees?
Q17
Can
my scheme terminate my membership of the scheme in the case of
1.retrenchment, 2. redundancy or 3
retirement?
Q18
May
pensioners' contributions be less than that of other
members?
Q19
May
medical schemes determine the contributions of retirees on
their income immediately prior to retirement as a subsequent
deemed income or salary
Q20
May
a medical scheme determine contributions on the basis of
individual high claims or provide for discounted of preferred
rates in respect of particular group of members/clients for
whatever reason?
Q21
If I
do not claim against my medical scheme, may I receive a
no-claim bonus or rebate?
Q22
On
what basis may contributions vary?
Q23
May
my medical scheme call upon me for increased contributions
with retrospective effect?
Q24
May a medical schemes request
pre-authorisation or second opinion in respect of certain benefits?
Q25
What
can I do if I am not satisfied with my current benefit
option?
MINIMUM
BENEFITS, WAITING PERIODS AND LATE JOINER
PENALTY
Q26
What
are prescribed minimum benefits
(PMB)?
Q27
What
is a designated service provider
(DSP)?
Q28
To
what extent are the prescribed minimum benefits
restricted?
Q29
What
constitutes the involuntary obtaining of services in respect
of the prescribed minimum benefits from
non-DSP?
Q30
What
are the types of waiting periods?
Q31
What does a waiting period mean?
Q32
When
do such waiting periods not apply?
Q33
How can I prove to a new scheme
that I was a member of another scheme?
Q34
What
is a late joiner penalty?
Q35
What
restrictions may a medical schemes impose on an
applicant?
Q36
Can
a medical scheme impose a condition-specific waiting period on
pregnancy?
COMPLAINTS
AGAINST SCHEMES
Q37
Where do I complain if claims are not paid
timeously or when I am dissatisfied with a decision taken by
the Scheme?
Q38
Is a
disputes committee entitled to require the aggrieved member to
pay any fees in relation to the
dispute?
Q39
What
remedies are available if I am not satisfied with the outcome
of Q37?
Q40
What
recourse do I have if I am not satisfied with the decision of
the Registrar?
Q41
How
does one present such an appeal to
Council?
Q42
Is
the Council entitled to award costs when an appeal is
considered?
CLAIMS,
PAYMENT OF ACCOUNT AND MEDICAL SAVINGS ACCOUNT
(MSA)
Q43
Within what period of time must my account for
services or claim reach my medical
scheme?
Q44
May
credit balances in my personal savings account be withdrawn in
cash?
Q45
May
contributions be paid from my savings
accounts?
Q46
Can co - payments in respect of
PMB benefits be paid out of my MSA?
Q47
How do I know whether or not my
scheme has paid and what amount has been paid in respect of a claim?
Q48
Within what period of time must the scheme pay my
claim?
Q49
What
is and ex GRATIA payment and do I have a right to such
benefits?
Q50
What
is the National Health Reference Price List
(NHRPL)?
Q51
Is a
provider of a health care service entitled to charge more than
the fees determined by medical schemes/the tariff specified in
the NHRPL?
MANAGEMENT
AND FUNCTIONING
Q52
Who
manages the affairs of a medical
scheme?
Q53
How
do medical schemes function?
Q54
May I participate in the operation of my scheme?
Q55
Are insurance products regulated by the Medical Schemes
Act?
Q56
What certainty does a member have that the benefits
offered by his scheme are guaranteed?
Q57
As members of a group, may we leave the medical scheme
to which we belong and claim our pro rata portion of the reserves?
Q58
Can a medical scheme change its rules and thereby move
the goal post?
TERMINATION
OF MEMBERSHIP BY THE SCHEME
Q59
When may my scheme terminate or suspend my membership?
ANSWERS:
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CATEGORY: GENERAL
INFORMATION
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Q1. When did the Medical Schemes Act come into
operation?
The
Medical Schemes Act 1998 (Act 131 of 1998) came into operation
on 1 February 1999. Regulations were introduced by Government
Gazette No 20556 dated 20 October 1999, with effect from 1
November 1999 and 1 January 2000 respectively.
Q2. How may a member ascertain what his
obligations to the scheme are and what his rights, benefits
contributions and limitations or benefits are from time to
time?
A
member is entitled on request, to copies of the scheme's
rules, financial statements, and annual reports upon payment
of a reasonable fee for such documents. On admission to
membership medical schemes are obliged to furnish members with
a summary of the registered rules which
comprise reciprocal rights and obligations of both the scheme
and members and all benefit options
and relevant contributions.
SELECTION
OF SCHEMES AND BENEFIT PLANS/OPTIONS
Q3. How do I as an individual select an
appropriate medical scheme?
1. Ensure
that the scheme is duly registered in terms of the Medical
Schemes Act 131 of 1998. The names, addresses and telephone
numbers of all registered schemes are published on the website
of the Council for Medical Schemes. The address is: http://www.medicalschemes.com/Consumer_Assistance/RegSchemes.aspx.
2. The
list is furthermore published annually in the Government
Gazette for general information. The office of the Registrar
will also provide you with information on registered
schemes.
3. Request
information about benefits, contributions, limitations and
exclusions from your
selected schemes.
4. If
you do employ the services of an agent, broker (intermediary),
ensure that he/she has been accredited by the Council for
Medical Schemes and that your selection of scheme is based on
informed consent. To ascertain whether a broker has been
accredited prospective members should insist that brokers
produce proof of accreditation with Council and/or verify the
broker accreditation status on: http://www.medicalschemes.com/Consumer_Assistance/FindBroker.aspx.
5. Request
the latest financial statements and annual report of the
scheme to avail yourself of their financial position. These
reports are available in the Council's Annual Report. To view
these Annual Reports, go to the following address on our
website: http://www.medicalschemes.com/Publications/Publications.aspx?catid=11
Q4. How do I know which benefit option to
select?
Ensure
that you understand how the benefit options operate and elect
according to your healthcare needs and what you can afford.
The registered rules of medical schemes fully disclose
detailed information regarding the relevant benefits and
contributions. It is essential that you obtain the rules of
the scheme or a summary thereof to verify all information
relevant to enable you to make an informed choice.
MEMBERSHIP,
CONTRIBUTIONS AND BENEFITS
Q5. What is a co - payment?
It
is a portion of the cost for which you are
responsible.
Q6. Is membership of a medical scheme available to
any person?
Yes,
except in a restricted membership scheme, for instance, where
a particular employer, profession, trade, industry, calling,
association or union has established a scheme exclusively for
its employees or members.
Q7. Can I belong to more than one medical scheme
at the same time?
No.
It is illegal.
Q8. Can a minor become a member?
Yes,
with the assistance of his/her parents or guardian, provided
that the relevant contributions are paid by him/her or on
behalf of him/her.
Q9. May a medical scheme refuse to admit my
dependant?
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, child
under the age of 21 or older and a child who is dependent upon
the member due to a mental or physical disability; 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, father, brother or sister of the
member. The scheme concerned may require proof of such
dependency and appropriate additional contributions in respect
of such extended cover must be expected.
Q10. Must a prospective member apply for
membership of a medical scheme through a
broker?
No,
there is no such provision in the Act. One can apply directly
to the scheme or opt to use the services of a broker
(intermediary).
Q11. If a member dies, will his registered
dependants still be covered?
Yes,
without any break in membership and provided contributions are
paid. It is important to inform the scheme if one chooses not
to continue.
Q12. Must I give notice to scheme in the event
that I wish to terminate membership?
Yes,
the notice period stipulated in the rules must be complied
with.
Q13. Am I entitled to benefits while serving
notice of termination?
Yes,
until the last day of membership provided contributions are
being paid.
Q14. Must my employer subsidize my contributions
to the medical scheme?
No,
subsidies are conditions of employment and the Act does not
address such conditions.
Q15. What role does my employer play in my
relationship with my scheme?
The
employer may determine whether or not the employees are
entitled to belong to one or more schemes or whether the
employees have total freedom of choice of scheme. The employer
also determines, generally within the framework of conditions
of service, negotiations between the workforce and organized
labour, such as trade unions/personnel organizations or staff,
what level of subsidies will apply to different categories of
employees or in general. Therefore, employers are not admitted
to membership but they play an important role in collecting
contributions and ensure payment thereof to the scheme
concerned.
Q16. Is my scheme entitled to cancel my
membership when the employer fails to pay the membership
fees?
Yes,
since the employer pays the contributions on behalf of its
employees and since the scheme has a contract with the member.
The Scheme must give the employer and or/member written notice
that if the contributions are not paid up within the
stipulated period in the rules membership may be
cancelled.
Q17. Can my scheme terminate my membership of the
scheme in the case of 1. retrenchment, 2. redundancy or 3.
retirement?
Closed
scheme - in case of 1 and 2 - Yes and 3 - No, Open scheme -
No, you simply continue your membership provided contributions
are paid.
Q18. May pensioners' contributions be less than
that of other members?
No,
contributions to a medical scheme may only be based upon a
member's income and/or his number of dependants.
Q19. May medical schemes determine the
contributions of retirees on their income immediately prior to
retirement as a subsequent deemed income or
salary.
Yes,
unless proof of a reduced income is submitted to the
Scheme.
Q20. May a medical scheme determine contributions
on the basis of individual high claims or provide for
discounted or preferred rates in respect of a particular group
of members/clients for whatever reason?
No,
contributions may only be based on a member's income and/or
the number of his dependants or both. The contributions apply
universally to all members who are enrolled and their
dependants.
Q21. If I do not claim from my medical scheme,
may I receive a no-claim bonus or rebate?
No,
the Act prohibits the payment of bonuses, rebates or
re-funding of any portion of contributions other than in
respect of savings accounts in certain circumstances.
Q22. On what basis may contributions
vary?
1.
Only
in respect of the cover provided. Different benefit
options/plans are priced differently depending on the level of
cover afforded.
2.
If
the rules of the scheme so provide, children may be charged a
reduced contribution.
Q23. May my medical scheme call upon me for
increased contributions with retrospective
effect?
No,
in terms of the Act a medical scheme must give members advance
written notice of any change in contributions and benefits or
any other condition affecting their membership.
Q24.
May a medical scheme request pre-authorisation or second opinions in respect of
certain benefits?
Yes,
except in an emergency where pre-authorisation should be obtained as stipulated
in the rules.
Q25.
What can I do if I am not satisfied with my current benefit option?
Instead
of changing schemes and be faced with waiting periods, a member can either buy
up in order to get better benefits or buy down for less contributions.
MINIMUM
BENEFITS, WAITING PERIODS AND LATE JOINER
PENALTY
Q26. What are prescribed minimum benefits
(PMBs)?
The
benefits in respect of relevant health services prescribed by
the regulations under the Act, and rendered by State hospitals
or designated
service provider according to
clinical protocols and criteria.
Q27. What is a designated service provider
(DSP?)
A
healthcare provider or group of providers selected by the
scheme as the preferred provider or providers to provide to
its members diagnosis, treatment and care in respect of one or
more prescribed minimumbenefit
conditions.
Q28. To what extent are the prescribed minimum
benefits restricted?
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
DSPs. 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.
Q29. What constitutes the involuntary obtaining
of services in respect of the PMBs from non - DSPs?
Involuntary
obtained means:
1.
the service was
not available from the designated service provider or would
not be provided without unreasonable delay;
2.
immediate
medical or surgical treatment for prescribed minimum benefit
condition was required under circumstances or at locations
which reasonably precluded the beneficiary from obtaining such
treatment from a designated service provider; or
3.
There was no
designated service provider within reasonable proximity to the
beneficiary's ordinary place of business or personal
residence.
Q30. What are the types of waiting
periods?
There are two
kinds of waiting periods i.e.:
1.
General waiting
period of up to three months.
2.
Condition-specific
waiting period of up to 12 months.
Q31. What does a waiting period
mean?
A
period during which contributions are payable without the
member being entitled to benefits.
Q32. When do waiting periods not
apply?
Waiting
periods do not apply in respect of:
1. Prescribed
minimum benefits other than specified in Q28
2. A
child dependant born during the period of
membership
3. A
member moving between benefit options unless he has to
complete the remaining period of previously imposed waiting
periods.
4. When an
individual has to involuntarily transfer to another scheme due
to a change of employment.
5. In
instances where an employer changes the medical scheme of
hisemployees
with effect from the beginning of the financial
year.
Q33. How can I prove to a new scheme that I was a
member of another scheme?
A
scheme must within 30 days of termination of membership, or at
any time at the request of a former member, or of a dependant
of a member, provide such person with a membership certificate
stating the period of cover and other prescribed information.
The applicant is also entitled to produce a sworn affidavit in
those instances where reasonable efforts to obtain documentary
evidence of previous membership were unsuccessful.
Q34. What is a late joiner
penalty?
It
is a penalty by way of additional contributions, imposed on
persons joining a scheme late in life i.e. an applicant who is
35 years of age or older who was not a member of one or more
medical schemes as from a date preceding 01 April 2001 without
a break in coverage exceeding three consecutive months since
01 April 2001.
Q35. What restrictions may a medical scheme
impose on an applicant?
1.
Late joiner
penalty
2.
Waiting
periods
Q36.
Can a medical scheme impose a condition - specific waiting
period on pregnancy?
Yes, in those
instances where the person was a beneficiary of a medical
scheme for up to 24 months.
COMPLAINTS
AGAINST SCHEMES
Q37. Where do I complain if claims are not paid
timeously or when I am dissatisfied with a decision taken by
the Scheme?
Any
complaint must first be lodged with the scheme concerned.
Written complaints would certainly be preferable, but all
schemes should also have dedicated telephone lines to handle
everyday complaints and enquiries. All schemes are also
required to have independent disputes committees where
members' disputes may be settled. Members and or their legal
representatives may be present at disputes committee meetings
to present their arguments. Legal representation is not
obligatory. Should all efforts fail to resolve an issue with
your scheme, you can submit your complaint to the Council for
medical Schemes Complaints Unit by either posting, faxing,
emailing or submit online by going to the following website
address: http://www.medicalschemes.com/Consumer_Assistance/CMain .
Q38. Is a disputes committee entitled to require
the aggrieved member to pay any fees in relation to the
dispute?
No,
there is no such provision.
Q39. What remedies are available if I am not
satisfied with the outcome of Q37?
Apart
from your rights to the courts, you may appeal to the
Council for Medical Schemes against such decision. The parties
concerned may appear before Council in person or through a
representative. Legal representation is not
obligatory.
Q40. What recourse do I have if I am not
satisfied with the decision of the Registrar?
You can lodge an appeal with the Appeal Board and only at this
stage a prescribed fee will be payable.
Q41. How does one present such an appeal to
Council?
In
the form of an affidavit directed to the Council and furnished
to the Registrar of Medical Schemes not later than three
months after the decision concerned was made by the disputes
committee.
Q42. Is the Council entitled to award costs when
an appeal is considered?
No,
there is no such provision.
CLAIMS,
PAYMENT OF ACCOUNTS AND MEDICAL SAVINGS ACCOUNT
(MSA)
Q43. Within what period of time must my account
for services or claim reach my medical scheme?
The
account must be submitted not later than the last day of the
fourth month following the month in which the service was
rendered.
Q44. May credit balances in my personal savings
account be withdrawn in cash?
Only
when you terminate your membership of the scheme or a benefit
option, without joining another medical scheme or benefit
option with a savings component.
Q45. May contributions be paid out of my savings
account?
No,
except on termination of membership. Funds in the MSA may be
used by the scheme to offset any debt owed by the member which
would include contributions.
Q46. Can co - payments in respect of PMB benefits
be paid out of my MSA?
No,
the Act specifically prohibits it.
Q47. How do I know whether or not my scheme has
paid and what amount has been paid in respect of a
claim?
Payment
of claims is regulated by the Act, which includes the dispatch
to a member of a statement containing full particulars of the
transaction, including the amount charged for every service
and the amount of the benefit awarded for each
service.
Q48. Within what period of time must the
scheme pay my claim?
If
the account or claim is correct and acceptable for payment, it
should be paid within 30 days of receipt of the
claim.
Q49. What is an ex
GRATIA payment
and do I have a right to such benefits?
It
is a discretionary benefit which a medical scheme may
consider, normally when the member suffers undue hardship.
Schemes are not obliged to make provision therefor in the
rules and members have no statutory right thereto.
Q50. What is National Health Reference
Price List (NHRPL)?
This is a
price list for health services published by Council for
Medical Schemes and is used to reimburse service
providers.
Q51. Is a provider of a health care service
entitled to charge more than the fees determined by medical
schemes / the tariff specified in the NHRPL?
Yes.
Health care providers are free to determine their own fees.
Consequently, if an account is in excess of the fee determined
by the rules of a medical scheme / NHRPL for a particular
service, the difference is for the account of the
member.
MANAGEMENT
AND FUNCTIONING
Q52. Who manages the affairs of a medical
scheme?
Board
of Trustees of which at least 50% must be elected or appointed
from the ranks of members. These persons must be fit and
proper to perform their duties, ensure that the interests of
members are protected and that the scheme is properly
administered. If they are guilty of misconduct, or reckless
trading, they may be held accountable for losses
incurred.
Q53. How do medical schemes
function?
Contributions
are pooled for the benefit of members. Schemes are
not-for-profit organizations and belong to the members.
Therefore, any surplus made remains in the scheme on the trust
principle, for the benefit of members and their
dependants.
Q54. May I participate in the operation of my
scheme?
Yes,
in terms of the Act, a medical scheme must provide for annual
general meetings (AGMs) where members may voice their views
and present motions. Medical schemes may also hold meetings at
different venues for the benefit of members or provide for
regional meetings to maximize member participation.
Q55. Are insurance products regulated by the
Medical Schemes Act?
Certain
stated benefit type insurance products, like hospital plans,
where the benefit is not coupled to a healthcare service
and/or the cost of such service, are not controlled by the
Medical Schemes Act. They fall under the jurisdiction of the
Financial Services
Board (FSB).
Q56. What certainty does a member have that the
benefits offered by his scheme are guaranteed?
In
terms of the Act a medical scheme must at all times have
assets to cover its liabilities. Furthermore, a scheme must,
over a period of time, hold surplus or accumulated funds equal
to at least 25% of gross annual contributions to ensure
financial stability.
Q57. As members of a group, may we leave the
medical scheme to which we belong and claim our pro rata
portion of the reserves?
No,
in terms of the Act, such reserves are assets of that scheme
and all moneys and assets belonging to a scheme must be kept
by that scheme.
Q58. Can a medical scheme change its rules and
thereby move the goal post?
Yes,
there is provision in the Act and in the rules of every
medical scheme on how the Board of Trustees may amend rules.
All rule amendments must however be approved and registered by
the Registrar of Medical Schemes as required by the Act. The
scheme will still notify members of such changes as they
entitled to it.
TERMINATION
OF MEMBERSHIP BY THE SCHEME
Q59. When may my scheme terminate or
suspend my membership?
Only
on the grounds of failure to pay membership fees timeously or
other debts owing to the scheme, submission of fraudulent
claims, committing other fraudulent acts, or the non
-disclosure of material information.
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