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).
Is membership of a medical scheme available to any person?
Yes, the open enrolment principle means that any person can join any medical scheme or their choice. The only exception is restricted medical schemes where you can only join if you meet the eligibility criteria. Eligibility criteria must be based on the grounds provided in the Act and which includes employment or membership of a particular employer, profession, trade, industry, calling, association or union has established a scheme exclusively for its employees or members.
Must I give notice to the scheme in the event that I wish to terminate membership?
Yes, if the rules of the scheme provide for such, the notice period stipulated in the rules must be complied with. Contributions must still be paid until the last effective date of membership.
What are the prescribed minimum benefits (PMBs)?
The benefits in respect of relevant health services prescribed by the regulations under the Act,
PMBs are defined in Regulation 7 and include the diagnosis, treatment and care costs of:
Any medical emergency;
The diagnosis and treatment pairs (DTPs) listed in Annexure A; and
The chronic conditions defined in the Chronic Disease List (CDL).
What are the types of waiting periods?
There are two kinds of waiting periods i.e.:
a. A general waiting period of up to three months.
b. A condition-specific waiting period of up to 12 months
What does a waiting period mean?
A period during which contributions are payable without the member being entitled to benefits.
What is a late joiner penalty?
It is a “fine” by way of additional contributions, imposed on persons joining a medical scheme when they are 35 years of age or older and was not a member of one or more medical schemes before 01 April 2001, without a break in membership exceeding three consecutive months since 01 April 2001. Penalties may be imposed on the late joiner according to a prescribed formula in the Regulations that determines a maximum penalty according to the applicant’s penalty band. The formula takes pervious creditable coverage with other medical schemes into consideration. Late joiner penalties are imposed indefinitely and do not expire after a certain period and the purpose is to place the late joiner and the other members who have been contributing towards a medical scheme from a young age on the same level as they receive the same benefits.
Within what period of time must my account for services or claim to reach my medical scheme?
The account must be submitted before the end of the fourth month from the last date of the service rendered as stated on the account. If the scheme is of the opinion that the claim is erroneous or unacceptable for payment it has to refer the claim back to the member and to the provider with reasons for doing so and provide them with an opportunity to correct the claim. The member and the provider must then be provided with a further 60 days from the date that it was returned, to resubmit the account. This period runs concurrently with the initial 4 months provided to submit the account which means that if the account is for example submitted on the same day that the services were rendered and then sent back for corrections, the account will only become stale on the last day of the fourth month from the date of service.
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.
Is a provider of a healthcare service entitled to charge more than the fees determined by medical schemes?
Yes. Healthcare 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.