Scheme Glossary

ACT

Act 131 of 1998, better known as the Medical Schemes Act, came into effect on 1 February, 1999. All South African medical schemes are legally obligated to adhere to the Act and comply with all regulations as published in the Government Gazette.

Acute condition

An acute condition is a disabling condition, short in nature, such as tonsillitis or appendicitis, which heals entirely after treatment.

Acute medicine

This is medicine used for diseases or conditions that have a rapid onset, severe symptoms, and that require a short course of medicine treatment. It can also mean medicines that you can claim for, but have not been classified as chronic medicine by the Scheme.

Administrator

An entity, accredited by the Council for Medical Schemes, that manages the day-to-day affairs of a medical scheme, i.e. collect the contributions, evaluate and pay out claims, manage membership data and queries, advise the medical scheme on cost management and clinical issues, etc.

Adult dependant

A member's spouse or partner, or any other of his/her registered dependants who are not child dependants.

Ambulance services

This includes all medically equipped transport like ambulances or air crafts utilised for medical emergencies.

Audiology

Measurement of hearing ability and correction of hearing problems.

Authorisation

Members of Anglo Medical Scheme are required to obtain authorisation before going into hospital if they are to receive non life-threatening or non-essential hospital treatment. Authorisation is also required for certain procedures, treatments and medical or surgical appliances. If approved, we will supply you with an authorisation number before the event.

Beneficiary

Every individual member and dependant who receives benefits from the Scheme is a beneficiary. Members are persons who belong to the Scheme and who pay their contributions as required by the Scheme. Members may register dependants according to the Rules. Members and dependants are both called beneficiaries of the Scheme.

Benefits

These are medical costs that the Scheme is covering for you. They are defined in our Rules.

Benefit option

A particular set of benefits, offered to a member and his/her registered dependants, as set out in the Rules. The three benefit options at Anglo Medical Scheme are: Value Care Plan, Standard Care Plan and Managed Care Plan.

Branded/patented medicine

Pharmaceutical companies incur high costs for research and development before a product is finally manufactured and released into the market. To recover these costs, the company is given the patent right to be the only manufacturer of the specific medicine brand for a number of years.

Cancer treatment

Please refer to "Oncology".

Capitation

Capitation is a healthcare model that involves a managed care organisation paying a set amount of money to a group of healthcare providers for a specific set of benefits.

Child dependant

A member's registered dependant who is not his/her spouse or partner and who is 23 years of age, or younger, on 1 January of the financial year for which contributions are raised; a mentally and/or physically disabled dependant who is above 23 years of age but whom the Board has permitted to be a "child dependant"; a younger sibling of an orphaned child dependant who has been deemed to be a member in terms of Rule 6.3.4.2, provided that such younger sibling is 23 years of age, or younger.

Chronic Condition

A chronic condition is a disease/condition which requires ongoing medication for a period of more than 6 months (often indefinitely).

Chronic medication/medicine

Chronic medication is the medicine, prescribed by a medical practitioner, that someone with a chronic condition needs. A medical scheme has the right to limit its expenditure in terms of PMBs by controlling which medicines and treatment options are covered in terms of its plans. Members might have to utilise a certain brand, or choose generic medicines, for example. Non PMB chronic medication are also managed in the same manner and certain benefit limits will apply.

Claim

After you've received medical treatment or healthcare services, you or the service provider submit a claim to the Scheme to request payment. In some instances the healthcare provider will insist on payment upfront. In this case you can then claim the amount back from your medical scheme.

Clinical management

Applying the Rules for treating specific conditions as well as medical procedures.

Co-payment

A co-payment is a certain amount or percentage of the cost of a medical procedure or healthcare services, for which the member is liable. The member pays the co-payment to the service provider for services not covered by the Scheme, for example the co-payment for your hospital stay.

Community rating

By law, all the members of a particular medical scheme plan have to pay equal monthly contributions. Community rating ensures that the sick and the elderly are not discriminated against.

Conservative dentistry

Basic dental services, such as fillings, extractions and oral hygiene.

Consultation

This refers to your visit to your service provider, such as your doctor, specialist, physiotherapist, etc.

Contribution

That is the fixed amount that you are paying monthly in arrears to be a member of the Scheme. This payment consists of amounts for each adult dependant and each child dependant that is registered under your membership as per the contribution schedules of the Scheme.

Council for Medical Schemes (CMS)

The body established in terms of Section 3 of the Medical Schemes Act 131 of 1998 to oversee the affairs of medical schemes. Also the ultimate complaints body for medical scheme members.

CT and MRI scans

Specialised high definition external scanning methods for internal bodily examinations.

Dependant

These are registered persons that the main member is supporting and who are not members or dependants of any other medical scheme. It can be a spouse, parent, sister, brother, and, adopted, step or foster children as well as any other person approved by the Scheme. Members may register dependants on the medical scheme according to the Scheme's Rules. Members and dependants are both called beneficiaries of the Scheme.

Designated Service Provider (DSP)

A DSP is a hospital or healthcare provider, who has an agreement with the administrator to provide treatment or services at a contracted rate and without any co-payments made by you, normally to treat a Prescribed Minimum Benefit (PMB) condition.

Disease management

Is an approach focusing on the patient's disease or condition. It can include patient counselling and education, behaviour modification, therapeutic guidelines, incentives, penalties and case management. One such example is where Anglo Medical Scheme provides management for the treatment of HIV and AIDS by One Health.

Dispensing licenses

According to the Medicines and Related Substances Control Amendment Act, a medical scheme can only pay out medicinal claims if the medicine was dispensed by a medical practitioner with a dispensing licence.

Elective surgery

Non-essential (planned optional) surgery, e.g. surgery to correct a condition that is not life threatening and not required for survival.

Emergency

An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or intervention. If the treatment/intervention is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or would place the person's life in jeopardy.

Employee

A person in the full-time employment of a participating employer.

Employer Trustee

A member of the Board who is appointed by the employer in terms of the Rules.

Exclusions

Exclusions are healthcare services that a medical scheme is legally permitted to exclude from its benefit offering. Examples are self-inflicted injuries and cosmetic surgery.

Formularies

Medicine lists defined by the medical scheme, managed care organisations and administrators used to treat various diseases and to control costs associated with medicines.

Generic medicine

A medicine with the same active ingredients as original brand-name medicines, usually at a lower cost.

HIV/Aids

The Human Immunodeficiency Virus is a retrovirus that breaks down the human body's immune system and can cause Acquired Immunodeficiency Syndrome (AIDS). AIDS is a condition where immune system begins to fail, leading to life-threatening opportunistic infections.

Homeopathy

Supplementary disease treatment using natural drugs.

ICD-10 codes

ICD stands for International Classification of Diseases and related problems. By law, every claim that is submitted to a medical scheme must include an ICD10 code. Every medical condition and diagnosis has a specific code. These codes are used primarily to enable medical schemes to accurately identify the conditions for which you sought healthcare services. This coding system then ensures that your claims for specific illnesses are paid out of the correct benefit and that healthcare providers are appropriately reimbursed for the services they rendered.

Inception date

This is the date on which you and your dependants become members of a scheme and your membership is registered. Your contributions are payable from this date.

Late joiner penalty

If you're 35 years or older and haven't been a member of a medical scheme for the last two years, you will be seen as a late joiner when you apply for membership or registration as a dependant on a medical scheme. A medical scheme may charge you with a "late joiner penalty", increasing your monthly contributions in accordance with the stipulations of the Medical Schemes Act.

Limits

Most in- and out- of hospital benefits are unlimited but there are some healthcare services such as dentistry and optometry that are subject to annual limits. It is important for you to familiarise yourself with these limits and to track your usage on your statement or by logging onto the AMS website.

Major medical benefits

That includes all the benefits for services available to you such as hospitalisation, procedures treatment you receive while in hospital.

Managed care/managed healthcare

Managed care refers to a number of strategies used by medical schemes to manage the costs associated with healthcare services and treatment and to promote the rational, appropriate use of healthcare resources. These strategies include, for example, formularies, protocols, authorisation, utilisation reviews, capitation etc. Medical schemes themselves, provider groups or managed care organisations (such as Prime Cure, who is Anglo Medical Scheme's managed care provider for Value Care Plan) can fulfil this role. Usually members only qualify for benefits if they have followed the guidelines and protocols the Scheme has set out to manage the illness.

Managed Care Plan

This is not related to the managed care/managed healthcare principle described in "Managed care/managed healthcare", but one of the Scheme's plans that you can choose as a member. For more detailed information about the Managed Care Plan, please click here.

Medical Savings Account (MSA) *Managed Care Plan only*

This is an amount advanced to you in the beginning of the year. You can use it for day-to-day healthcare expenses like acute mediation, consultations, auxiliary health services etc. as long as you have money available. Any money left over at the end of the year will be carried over to the next year.

Medical scheme

An organisation, registered with the Council for Medical Schemes, to provide for and manage the healthcare needs of its beneficiaries, to obtain contributions from members on a not-for-profit basis. Medical schemes may register more than one plan that provides different types of benefits at different rates of contributions.

Member Trustee

A member of the Board who is elected by members of the Scheme.

Member

Members of medical schemes are persons who belong to that medical scheme and who pay their contributions as required by the medical scheme. Members may register dependants on the medical scheme according to the medical scheme's rules. Members and dependants are both called beneficiaries of the medical scheme.

NAPPI codes

National Pharmaceutical Pricing Index (NAPPI) codes are used to provide information about pharmaceutical and surgical products. This includes details about the manufacturer, registration, strength and dosage.

National Health Reference Price List (NHRPL)

The NHRPL is a national pricing system regulated by the Department of Health and the Council for Medical Schemes. Basically, the NHRPL should stipulate the rates to which medical schemes must adhere in terms of benefit payments. However, medical service providers are not bound by this rate and some thus charge significantly higher rates. In such cases, members are liable for the difference between the provider's rate and the NHRPL rate.

Oncology

This field of medicine is included in the treatment of cancer. It can consist of chemotherapy and radiation therapy. If you're a member of a medical scheme, you will probably have to join a disease management programme, of which your oncology treatment will form a part.

PAT (Pharmacist Advised Therapy)

Most common ailments can be treated effectively by medicines available from your pharmacy without a doctor's prescription. Cover for PAT medicines varies according to the plan type you have chosen.

Physical trauma

A severe bodily injury due to violence or an accident, e.g. gunshot, knife-wound, fracture or motor vehicle accident. The suffering of serious and life-threatening physical injury, potentially resulting in secondary complications such as shock, respiratory failure and death. This includes penetrating and blunt force injuries.

Prescribed Minimum Benefit (PMB) conditions

These are conditions which all medical schemes are required to cover as set out by the Council for Medical Schemes according to clinical guidelines. You may be required to use a Designated Service Provider (DSP). A DSP is a healthcare provider who has an agreement with the administrator to provide treatment or services at a contracted rate and without any co-payments by you.

Pre-existing condition

A pre-existing condition refers to a condition that a prospective member has been diagnosed with, where treatment has been advised by a medical practitioner, within one year prior to his or her membership application.

Principal Officer (PO)

The Principal Offer is the executive officer of a medical scheme and responsible for ensuring that the medical scheme's operations run smoothly. The Principal Officer reports to a Board of Trustees.

Primary healthcare provider

A primary healthcare provider deals with you and your family's day-to-day healthcare needs - such as treating a minor burn or flu etc. These can include general practitioners (GP's) and nurses.

Pro-rata benefits

Some of your benefits are given on a calendar year basis, which means that you have an annual limit. If you join a medical scheme on a date other than 1 January, your benefits are calculated pro-rata, which means that you receive a year's benefits in advance. If you exceed your annual limit, you'll have to pay the excess costs out of your own pocket.

Private hospital

Unlike State hospitals, private hospital groups are run as businesses if you're a member of Anglo Medical Scheme, you will in most cases receive healthcare in a private hospital.

Risk/scheme risk

This category of benefits on Standard Care Plan and Managed Care Plan are paid by the Scheme (risk) and provides cover for procedures over which members have little or no control and includes services such as:

• Prescribed Minimum Benefits (PMBs)
• Chronic medicine subject to authorisation by the Scheme's chronic medicine team
• Cancer, diabetes and kidney treatment, subject to registration on the disease management programmes
• HIV and AIDS treatment, subject to registration on the HIV/AIDS programme
• In-hospital professional services
• Maternity, subject to registration on the maternity management programme
• Surgery and related expenses while in hospital
• Blood transfusions
• Internal prostheses, subject to the annual limit
• Medical and surgical appliances, subject to the annual limit
• Radiology and pathology in hospital and out of hospital
• Specialised Radiology, subject to authorisation
• Procedures in doctors' rooms as per defined Scheme list
• Alternatives to hospitalisation (step-down facilities, private nursing, hospice, frail care, substance abuse and drug addiction) - all subject to authorisation.

 

Roll-over benefits

Roll-over benefits are unused medical savings (Managed Care Plan only) that a medical scheme carries over from the previous year, so that a member may take advantage of those benefits in the current year.

Rules

According to the Medical Schemes Act, rules of a medical scheme include:

• The provisions of the law, charter, deed of settlement, memorandum of association or other document by which by which the medical scheme is constituted.
• The articles of association or other rules for the conduct of the business of the medical scheme.
• The provisions relating to the benefits which may be granted by and the contributions which may become payable to the medical scheme.

 

To view the rules of Anglo Medical Scheme, please click here.

Scheme Reimbursement Rate (SRR)

This is a rate set by Anglo Medical Scheme which is a rate for the payment of services rendered by hospitals and other service providers.

Service Date

This can be the date on which you are discharged from hospital, the date you have received a medical service, or medical supplies.

Service provider

This is anyone who gives you medical advice and service, such as your doctor, dentist, pharmacist, nurse, medical auxiliary or hospital.

Specialist

For specialised medical treatment that cannot be offered by your general practitioner (GP), you can receive care from a wide range of specialists, including specialist physician, cardiologists, urologists, gynaecologists, pathologists, a wide range of surgeons and in the case of an operation, anaesthetists.

State hospital

This is the system of hospitals of each provincial government in South Africa. These can include training hospitals where nurses, doctors, specialists and other medical professionals are trained. If your local State hospital does not offer specialist treatment of a disease, your State health service provides any necessary transfer to other State hospitals outside your province of residence where you can obtain the necessary treatment.

Trustees

At Anglo Medical Scheme the Board of Trustees consists of 50% member elected and 50% employer- appointed Trustees. The Trustees take ultimate responsibility for the running of the Scheme in the interests of all its members. Trustees are liable for the decisions they make. They have to balance financial security with health needs of their scheme.

Waiting period

A period during which a beneficiary is not entitled to claim any benefits.

Waiting period (condition specific)

Depending on your previous medical scheme history, a medical scheme may impose a waiting period of up to 12 months from the inception date of your membership, for any pre-existing condition/s. No benefits will be paid out for any costs involved for this condition.

Waiting period (general)

This refers to a three-month general waiting period on benefits for new members. No benefits are paid out during this period, not even from a MSA (Medical Savings Account), except for some procedures that are covered within the PMBs, as prescribed by the Medical Schemes Act.