AdultRefers to the member and dependants who are 22 or older at any time in the year of cover.
CBTCAMAF Base Tariff - the maximum rate paid by the Scheme to providers of healthcare services, based on 2009 RPL (Medical Aid) rates, increased annually by CPI. Tariff differs per type of service provider and % paid on different options.
CDLChronic Disease List - the list of PMB’s includes 26 common chronic conditions called CDL’s. Schemes must provide cover for the diagnosis, treatment and care of these conditions. Members must register their conditions to qualify for benefits. Schemes can provide protocols in terms of the range (RP and Formularies) and delivery of medication (DSP’s).
ChildRefers to a dependant who is younger than an adult, as defined above.
Childbirth ConfinementThe period of time just before and during the birth of a child
CML/FormularyCondition Medicine List - once a patient’s chronic condition has been registered, a patient will have access to the CML. This is a list of drugs, appropriate for the condition, that do not require authorisation. This is maintained by the Scheme and differs per Option. Reference pricing may still apply.
Dispensing FeesFee negotiated by the Scheme with Network pharmacies and added to SEP.
DSPThe network of service providers contracted to provide healthcare services to members, eg. Independent Clinical Oncology Network (ICON), HIV programme (LifeSense), PPN for optical benefits, Pharmacy networks for all chronic medications, Netcare 911 for emergency transport, Netcare hospital group for Network Choice hospital admissions and Life Healthcare and Netcare hospital groups for Alliance Network, Double Network, Vital Network and Essential Network for hospital admissions.
DTPThe Regulations to the Medical Schemes Act in Annexure A provide a list of conditions identified as Prescribed Minimum Benefits. The List is in the form of Diagnosis Treatment Pairs (DTP’s). A DTP links a specific diagnosis to a treatment/procedure and therefore broadly indicates how each of the 271 PMB conditions should be treated. These treatment pairs cover serious and acute medical problems that include the cost of diagnosis, treatment and care of these conditions. Members must register their conditions to qualify for benefits. Schemes can provide protocols in terms of the range (RP and Formularies) and delivery of medication (DSP’s).
ICD 10 CODEInternational Classification of Diseases and Related Health Problems (10th revision) - a coding system developed by the World Health Organisation (WHO) that translates the written description of medical and health information into standard codes, e.g. J03.9 is an ICD-10 code for acute tonsillitis (unspecified) and G40.9 denotes epilepsy (unspecified). These codes are used to inform medical schemes about what conditions their members were treated for so that claims can be paid from the correct benefit.
IncomeTotal cost to company prior to deductions.
Medical EmergencyA sudden and, at the time, unexpected onset of a health condition or injury that needs immediate attention, where failure to provide such attention could result in the risk of loss of life or permanent damage to a bodily function or body part.
Metabolic ScreeningNewborn screening whereby rare disorders are detected by a blood test done 48 - 72 hours after birth.
MMAPMaximum Medical Aid Price - is a reference price model and determines the maximum medical scheme price that medical schemes will reimburse for an interchangeable multi-source pharmaceutical product (generic) on the relevant option. MMAP applies to all options for chronic medication.
MSAMedical Savings Account - a savings account that accrues monthly but the annualised amount of savings is available immediately and can be used for:
• top up on cost of service charged by a doctor
• extension when an overall benefit has been exceeded
• exclusion from benefits
• payment of day to day claims on Essential Plus and Essential Network options
Negotiated RateThis is the rate, negotiated by the scheme with the service provider/group of service providers, eg. hospitals and pathologists.
Nominated GP Each beneficiary on Alliance Network, Double Network and Network Choice options needs to nominate a Network GP each year and use that GP only. An alternative nominated GP will be allowed should the primary nominated GP not be available. This is to improve care co-ordination.
PMBPrescribed Minimum Benefits - as set out in the Medical Schemes Act, 1998. Medical schemes have to cover the costs related to the diagnosis, treatment and care of:
• Any emergency medical condition
• A limited set of 271 medical conditions (Defined in DTP’s)
• 26 chronic conditions defined in the CDL
• These costs may not be paid from the member’s savings benefit and cost saving measures can be used by way of utilising DSP’s, Reference Pricing and Formularies.
Pre-authorisationA member must obtain prior approval for an intended admission to hospital. Failure to pre-authorise could result in wholly or partly disallowing the claim or imposing a penalty of 20% of related accounts up to a maximum of R 2 500. Emergency treatment is not subject to Pre-authorisation but members should notify the Scheme as soon as possible after the event.
ProtocolMeans a set of guidelines in relation to diagnostic testing and management of specific conditions and includes, but is not limited to, clinical practice guidelines, standard treatment guidelines and disease management guidelines.
Risk ContributionsThose funds allocated to the overall pool of funds for the payment of all claims other than those paid from the Medical Savings Account.
RPReference Pricing - the maximum price for which the Scheme will be liable for specific medicine or classes of medicine, listed on the Scheme’s Condition Medicine List (CML). The reference price varies per option and where a drug is above the reference price it is indicated that a co-payment will apply. This includes MMAP.
SEPSingle Exit Price - nationally applied pricing for medication as determined by the Department of Health and the pharmaceutical manufacturers.
TTOTo Take Out - medication supplied by the hospital for use after the date of discharge from hospital - limited to a 7 day supply.