People battle to understand medical scheme terminology, acronyms, industry jargon and benefits.
In order to assist you to be an informed member of Genesis Medical Scheme, we discuss below some important terms and definitions that you should know. That said, the first thing that you must remember at all times, is that when joining any medical scheme, you enter into a valid binding legal contract, the terms and conditions of which are contained in the Rules of the scheme that have been registered by the Registrar of Medical Schemes, as being compliant with the Medical Schemes Act and fair to members. Therefore, all benefits and obligations are expressly set out in the Rules. This situation ensures that every member is treated equally and fairly.
“admission / procedure reference number”
This means that Genesis will reimburse the costs for treatment in accordance with the Scheme Rules. The hospital costs will be reimbursed at the scale of benefits (which usually means at the rate at which the hospitals charge the Scheme) and the doctor and other service provider costs will be reimbursed in accordance with the Scheme Rules applicable to the benefit option that the member has chosen. Service providers may charge more than the reimbursement rate applicable to the member’s benefit option. It is important to remember that doctors may not be employed by private hospitals and so they charge a fee separate from that of the hospital. The position in public hospitals is different as the law allows the State to employ doctors.
The fact that the Scheme issues a hospital admission reference number for an intended treatment and / or procedure(s) is not a guarantee of payment or reimbursement of the costs by Genesis. The reimbursement of all claims is always subject to adjudication and audit in accordance with the benefits provided in the Scheme Rules.
All consultations, procedures and / or special investigations done on the pre-operative day and for which a hospital facility is not necessary will, at the Scheme’s discretion, be reimbursed from the member’s savings account (if available) or be for the member’s personal account.
Prescribed minimum benefits (PMBs) as prescribed in the Medical Schemes Act will be reimbursed as prescribed in the Act and as detailed below.
“child dependant”
means a child (natural child, stepchild, legally adopted child or a child placed in the legal custody of the member of his / her spouse or partner) who is under the age of twenty one (21) years and who is registered as a child dependant on the Scheme.
“condition specific waiting period”
means a period of up to twelve (12) months calculated from the date of commencement of membership of the Scheme during which time a beneficiary is not entitled to claim benefits in respect of the specified condition(s) for which medical advice, diagnosis, care or treatment was recommended or received.
During this waiting period, members have to pay their normal monthly contributions and any medical costs associated with the pre-existing health condition(s), as specified when they join, will be excluded during the first 12 months of membership. All such costs will be for the member’s own pocket, except in certain instances with claims relating to PMBs and in which instance the treatment and / or service have to be obtained from any public or state hospital in South Africa and the Uniform Patient Fee Schedule (UPFS) tariff will apply.
“emergency medical condition”
means the sudden and, at the time unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide such treatment would result in serious impairment of bodily functions, or serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy. It is important to remember that the condition must require “immediate” life-saving treatment and not “urgent” treatment.
“exclusions”
means expenses that are incurred in respect of certain conditions, procedures and services (listed in Annexure C of the Scheme Rules) that will not be covered by the Scheme, unless expressly stated to the contrary in the Rules / Annexures / Appendices, or as otherwise determined by the Board. Savings account facilities, where applicable and to the extent available, may be used to cover expenses where indicated. Please ensure that you familiarise yourself with these exclusions in the Rules.
“general waiting period”
means a period of up to three (3) months calculated from the date of commencement of membership of the Scheme during which time a beneficiary is not entitled to claim any benefits.
During this period, members have to pay their normal monthly contributions, but are not entitled to claim any benefits whatsoever, except in certain instances with claims relating to PMBs and in which instance the treatment and / or service have to be obtained from any public or state hospital in South Africa and the Uniform Patient Fee Schedule (UPFS) tariff will apply.
“Genesis Private Rates”
means an amount not exceeding the scale of benefits (“medical aid rate”) times two (2). This rate serves as a limitation on the liability of Genesis, but does not restrict the amount that a service provider (i.e. doctor / specialist) may charge. What this means is that you must negotiate a fee with your doctor, who is free to charge whatever amount he / she likes. Genesis will only reimburse your claim at the rate set out in the Rules that may be lower than the fee charged by your doctor. Obviously, in an emergency situation the account will be paid in full so long as the emergency is evident.
“ICD-10 code”
means a reference code that is used by doctors for the International Classification of Disease (10th revision). It is a coding system developed by the World Health Organisation (WHO), that translates the written description of medical and health information into standard codes. These codes appear on healthcare provider accounts and are used to inform medical schemes about what conditions their members were treated for so that claims can be settled correctly.
“late joiner”
means an any person who, at the date of application for membership, is thirty five (35) years of age or older. It excludes any person who was a member of a medical scheme prior to 1 April 2001 and who has been without a break in cover exceeding 3 consecutive months since that date.
“late joiner penalty” (“LJP”)
means, with reference to “late joiner” above, the premium penalty that a member may pay when joining the Scheme after the age of thirty five (35) years. Late joiner premium penalties will be paid for the duration of membership of the Scheme and shall not exceed the following bands:
“medical savings”
means in relation to members on the Private Plus and Private Comprehensive options, a portion of their monthly contribution that is allocated to an individual Savings Account for their exclusive use subject to the conditions contained in the Rules. Unless expressly stated to the contrary, the savings facility shall be available for the exclusive purpose of paying benefits for the member and his/her registered dependants that are ordinarily not covered by the Scheme, e.g. day-to-day medical expenses or co-payments on certain provider accounts when the tariff charged, exceeds the tariff covered by Genesis in terms of its Rules.
At the beginning of each three months period in any financial year, the Scheme will make available a savings facility not exceeding three times the monthly savings contribution that is included in the member’s monthly contribution. In addition, any amount unused from a previous three month period in the same financial year, or any unused balance that accumulated from a previous year, plus any other amount transferred from another medical scheme, will be added to the member’s available savings balance.
Savings benefit of those members joining the Scheme during a financial year, will be prorated to the end of the applicable three month period of that financial year.
“member”
means any person who is admitted as a member of Genesis and who contributes to the Scheme in order to qualify for the benefits in terms of the Rules. It does not include a dependant.
“member family”
means the member and all his / her registered dependants.
“non-declaration of information” (“non-dec”)
means the failure to disclose, or the misrepresentation of, all or some of the relevant facts or details regarding the medical history of the member and / or his / her registered dependants at the time of application for membership.
“prescribed minimum benefits” (“PMBs”)
means the benefits in respect of relevant health services as prescribed by the Minister of Health in terms of the Medical Schemes Act.
Genesis covers all approved conditions, including PMBs, in private hospitals, where the benefits and limits, as set out in the Rules, apply. Hospital accounts, including treatment for PMBs, will usually be paid in full in terms of tariff agreements with the hospital. In private hospitals, the charges of attending doctors / specialists and other healthcare service providers, even for PMBs, will be reimbursed at 100% or 200% of Medical Aid Rate, depending which benefit option you are on.
This funding applies to all claims for treatment in private hospitals, even if the condition is listed as a PMB. Shortfalls relating to treatment received in private hospitals usually pertain to charges for attending doctors / specialists if they charge more than 100% or 200% of the Medical Aid Rate. To this end, should your claim be listed as a PMB and you want it to be paid according to the law as provided for in section 29(1)(p) of the Medical Schemes Act (“paid in full subject to PMB level of care”), then treatment must be obtained from any public or state hospital in South Africa and the Uniform Patient Fee Schedule (UPFS) tariff will apply. In short, PMB treatment in private hospitals is reimbursed in terms of the Rules where limits may apply. PMB treatment in public or state hospitals will be reimbursed subject to PMB level of care as prescribed in the Medical Schemes Act. This means that you must receive the same entitlement to treatment that applies to a public or state hospital patient as set out in the regulations to the Act.
“pro-ration of benefits”
means that, when you join Genesis during the financial year (e.g. not in January), certain stated benefits, such as medical savings, consultations, in-hospital dental treatment, internal medical / surgical appliances or prosthetics, etc., will be pro-rated from the date of commencement of membership to the end of that year.
An example of this is your savings benefit. If you join the Scheme on 1 July, you will effectively have half of the annual savings benefit.
“reference price”
means the price at which a service provider will supply a clinically appropriate drug in terms of the formulary in use by the Scheme.
“rules”
means the terms and conditions of a medical scheme under which the Registrar of Medical Schemes registers a medical scheme. The Rules of a scheme determine how a scheme must conduct its business in line with the provisions of the Medical Scheme Act, as well as the scope and level of benefits that are available to the beneficiaries of a scheme in respect of its various registered benefit options.
“scale of benefits”
(also referred to as “medical aid rate”) means the schedule of tariffs in respect of relevant health services determined by Genesis from time to time, or the fee determined in terms of any agreement between the Scheme and a service provider or group of providers in respect of the payment of relevant health services.
“medically appropriate”
means the reasonable determination by the Scheme, in relation to a health service, that the health service required is or was:
√ rational or reasonable and supported by sound scientific evidence; and / or
√ cost-effective in relation to available alternatives; and / or
√ not principally selected for consideration of comfort or convenience; and / or
√ in accordance with generally accepted guidelines and protocols of medical practice.
The definitions and explanations set out above may have been summarised for the sake of simplicity. For further detail, please refer to the registered Rules of the Scheme. It is very important that you understand the benefits and obligations that membership entitles you to. The Rules, no matter how simply written, are complex and we will try to assist you with any queries.
Should you have any questions, please do give us a call on 0860 10 20 10 or email us to genesis@genesismedical.co.za. One of our friendly consultants will gladly assist you.
