Glossary of Industry Related Terms

Acute Condition An acute condition is a self-limiting condition which disappears after treatment e.g. appendicitis and tonsillitis.
Capitation The healthcare model whereby a fixed amount of money is paid by a managed care organisation to a network of healthcare providers. The opposite of a capitation model is a fee-for-service model.
Chronic Condition A chronic condition is a condition which has to be treated on an ongoing basis for more than three months.
Chronic Disease List (CDL) The CDL is a list of twenty-five conditions which may not be excluded by medical schemes.
Chronic Illness A chronic illness is a life-threatening condition that requires ongoing treatment for a period of over 12 months e.g. diabetes and asthma.
Chronic Medication All medical schemes are entitled to limit the expenses for Prescribed Minimum Benefits by controlling your choice of medication and other treatment procedures. Cover can be limited to certain brands or generic medication.
Claims Paying Ability This is the number of monthly claims that the scheme is able to cover with its existing cash and cash equivalents.
Co-payment A portion of the cost of a procedure for which the member is responsible which can be expressed as a rand amount or a percentage of the total bill.
Community Rating In terms of legislation, all members of a medical scheme option must pay the same contributions and cannot be asked to pay more due to age or ill health.
Continuation Membership Principal members of closed medical schemes are entitled to remain on the scheme after retirement even if the employer no longer pays the contribution. In the event of the death of the principal member, the dependants will still be covered by the scheme.
Contracted Out If a doctor is contracted out, it means that s/he charges fees higher than the NRPL rates set out by the Council for Medical Schemes.
Credit Rating Global Credit Rating (GCR), an international credit rating company, rates a medical scheme’s ability to pay claims or a hospital’s ability to pay for services.
Deductible A set rand amount that must be paid upfront by the member for a defined list of procedures.
Designated Service Provider A group of medical service providers specified in the fund rules from whom services must be obtained to have unlimited and co-payment free benefits.
Exclusions Some medical conditions and procedures may be excluded from medical schemes e.g. cosmetic surgery and self-inflicted injuries.
ICD-10 Codes This code is based on a medical diagnosis in terms of an international classification of diseases developed by the World Health Organisation which must be contained on all claims submitted to medical schemes, in terms of the Medical Schemes Act (1998).
Late Joiner Penalty The Medical Schemes Act makes provision for schemes to apply a late joiner penalty to members over the age of 35. Depending on the number of years that you have not belonged to a registered South African medical scheme over the age of 35, the late joiner penalty is calculated as a percentage of your monthly contribution and will be added to your monthly contribution. For further information on late joiner penalties, click on the link.
Medical Savings Account (MSA) A pool of the member’s own money set aside from the contribution for payment of day-to-day medical expenses.
Pre-authorisation Hospital admissions for non-essential or non-life threatening procedures need to be authorised by the medical scheme prior to the member being admitted.
Pre-existing Condition A condition for which a member has received medical advice, diagnosis, care or treatment was recommended within 12 months prior to application for membership to a medical scheme.
Prescribed Minimum Benefits The Medical Schemes Act requires that all medical schemes provide cover for the CDL conditions.
Roll-over Benefits Unused medical savings that are carried over from one year to the next.
Waiting Periods When a member joins a medical scheme two waiting periods can be imposed: a three month general waiting period during which no claims will be paid and/or a twelve month exclusion for cover for pre-existing conditions.
 
If you can think of any additional medical aid related terms, that you know are often misunderstood, please send us an email. Just write the term in the subject line and we will add it to the list above. Thank you for helping us to build this site into a valuable medical aid resource for all.

 


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