Glossary of Terms

Glossary of Terms
  • Active Ingredient – is the main substance/s in medication that is responsible for the clinical action on a human.
  • Acute Medication – medicine taken for an illness which has a short term set of symptoms, e.g. painkiller for a headache, antibiotic for flu.
  • Additional Chronic Diseases – a list of chronic diseases in addition to the 27 legislated diseases, for which the scheme provides benefits – see brochure.
  • Adult – refers to the member and dependants who are 22 or older at any time in the year of cover.
  • Agreed Tariff – see “Scheme Tariff”
  • Allied Health Workers – includes, but is not limited to practioners such as Acupuncturists, Chiropractors, Homeopaths.
  • Benefit Option – a group of benefits offered by a scheme to its members at a defined monthly cost – see brochure.
  • Branded or Patented Medicine – pharmaceutical companies incur high costs for research and development of products prior to manufacture and approval for release into the market. To recover these costs, the company is given the patent right to be the sole manufacturer of the specific medication for a number of years, without generic equivalents.
  • Capitated Services – specialised clinical or administrative services provided by preferred providers, which are paid for on a “per member per month” basis by the scheme, up to an agreed limit e.g., Preferred Provider Network for spectacles.
  • CBT – CAMAF Base Tariff – the maximum tariff paid by the scheme to providers of healthcare services. Tariff differs per type of service provider and % paid on different options.
  • CDL – Chronic Disease List – the list of Prescribed Minimum Benefits includes 27 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 apply protocols in terms of the range (Reference Pricing and Formularies) and delivery of medication (Designated Service Providers) – see brochure.
  • Child – Refers to a dependant who is younger than an adult as defined above.
  • Chronic Condition – an illness or disease which requires treatment on a long term or permanent basis and which could be life threatening if not treated appropriately e.g., diabetes, high cholesterol, high blood pressure.
  • Claim – when a member receives medical treatment/medication, the service provider will submit an account for the costs incurred either to you or your medical scheme.
  • Clinical Algorithms or Protocols – a step by step process of applying evidence based treatment for a successful outcome in treating the condition/illness.
  • CML/Formulary – Condition Medicine List – once a CAMAF member’s chronic condition has been registered, they will have access to the CML. This is a list of drugs, appropriate for the condition, that do not require authorisation. This is regularly updated and maintained by the scheme and differs per option. Reference pricing may still apply.
  • Community Rated Contribution – a contribution rate determined by the risk presented by a group of people rather than on an individual basis.
  • Consultation – the time spent with your service provider in order to diagnose or suggest treatment for a condition, for which an account may be rendered.
  • Contracted In or Out – this is an outdated term, (still used by some people today) to describe a service provider that charged medical aid rates. There is now no standard “medical aid rate” and service providers are no longer contractually bound to medical schemes. As a result of the Competition Commission, the setting of standard medical aid rates was outlawed – rates of payment must be decided individually by medical schemes and service providers in turn have the freedom to set their own fees. Medical schemes negotiate annually with large group practices e.g., hospitals and pathologists, and these are known as “negotiated rates” but it is not possible for all schemes to negotiate fees with individual service providers. CAMAF sets a rate for individual service providers known as the CBT – see “CBT”.
  • Contribution – a fixed monthly amount paid to your medical scheme, for you and each beneficiary registered. This can be a fixed monthly fee for the option or determined by your income and number of beneficiaries, depending on the scheme option chosen by you.
  • Co-payment – is a percentage of a claim or a pre-determined amount for which a member is liable, as a result of non compliance with a protocol or formulary. Some schemes levy a co-payment on certain procedures or surgery in terms of their rules and cost containment processes. CAMAF does not levy pre-determined co- payments on procedures or surgery.
  • Day to Day Benefits – benefits for services obtained outside of hospital. There are various mechanisms used by schemes to limit liability e.g., utilisation of savings and subsequent thresholds, overall annual limits, capitation etc.
  • Dependant – a member’s spouse or partner, dependent child, intermediate member of the main member’s family for whom the member is liable for family care and support.
  • Designated Service Provider (DSP) – a network of service providers contracted to provide healthcare services to members, e.g. Diabetes programme (CDE), PPN for optical benefits on First Choice and Network Choice, Pharmacy networks for all chronic medication and the Netcare hospital group for the Network Choice hospital admissions.
  • Disease Management – a holistic approach to managing a patient’s condition, which can include counselling and education, behaviour modification, incentives for compliance and possible penalties for non-compliance. The patient usually has to cooperate with the programme in order to receive the benefits.
  • Dispensing Fees – see “Medicine Dispensing Fees
  • DTP (Diagnosis and Treatment Pairs) – the Regulations to the Medical Schemes Act in Annexure A provide a list of conditions identified as Prescribed Minimum Benefits. A DTP links a specific diagnosis to a treatment /procedure and therefore broadly indicates how each of the 270 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.
  • Formulary – a defined list of preferred medication to treat specific diseases, based on effectiveness and cost.
  • Generic Medication – these are medicines that contain exactly the same active ingredients, strength, formulation and presentation as the original branded product. They can be produced by the original manufacturer or another manufacturer, once the patent for the branded product has expired.
  • Hospital Plan – this type of option covers only in-patient hospital treatment, while the member is liable for all other costs, unless for PMB conditions. Some insurance products which are labelled as Hospital Plans (not to be confused with a Medical Scheme hospital option) offer a pre-determined monetary pay-out per day of in-patient hospitalisation, not related to the actual cost of the stay.
  • ICD10 Code – Stands for International Classification of Diseases and Related Health Problems (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, 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.
  • Income – Gross income, which accrues from any source whatsoever to the member.

  • Late Joiner Penalty a penalty by way of additional contributions, imposed on persons joining a scheme late in life i.e., an applicant who is 35 years of age or older who was not a member of one or more medical schemes as from a date preceding 01 April 2001 without a break in coverage exceeding three consecutive months since 01 April 2001.Penalty bands – number of years without cover after the age of 35 years Maximum penalty – for life>1 – 4 years >0.05 multiplied by the relevant contribution
    >5 – 14 years >0.25 multiplied by the relevant contribution
    >15 – 24 years >0.50 multiplied by the relevant contribution
    >25 + years >0.75 multiplied by the relevant contribution
  • Managed Health Care a programme which manages health care resources and services to ensure that members obtain the most effective, rational and appropriate care for their condition. In some cases it could mean that a member would be required to join the case management programme of the scheme e.g., Oncology for cancer treatment.
  • Medicine Dispensing Fee is the legislated maximum fee that may be charged by a pharmacist or dispensing doctor for the dispensing of medicine.
  • Medicine Formulary see Formulary€.
  • Medicine Schedule all medication in SA is categorised according to the active ingredient/s contained in the medication. From schedule 3 upwards a doctor’s prescription is required. Some drugs have a high scheduling status (schedule 5 – 7), which include antidepressants, strong pain medication and sleeping tablets, as they are either habit forming or have potentially dangerous side effects if used incorrectly.
  • Metabolic Screening new-born screening, whereby rare disorders are detected by a blood test done 48 – 72 hours after birth. The process makes use of the latest technology available to screen for up to 15 different types of inborn errors of metabolism (IEM). By testing for these metabolic disorders, parents can be assured that treatment and dietary changes can be implemented sooner rather than later. A completed report is returned to the referring doctor, who would discuss the results with the parents and perform post-test counselling if necessary.
  • MMAP Maximum Medical Aid Price is a reference price model, which determines the maximum medical scheme price that your medical scheme will reimburse for an interchangeable multi-source pharmaceutical product (generic) on the relevant option.
  • MSA – Medical Savings Account accrued monthly to an account held in the member’s name but the annualised amount of savings is available immediately on CAMAF and can be used for: top up on cost of service charged by a doctor, where the doctor has charged more than the rate that the scheme pays, benefit extension when an overall limit has been reached, exclusions from benefits e.g., cosmetic surgery; upon resignation can be used to offset any medical scheme debt owed by the member. If a member resigns from membership during the year (prior to December) and has used the full year’s MSA, the shortfall is due to be refunded by the member to the scheme.
  • Negotiated Rate this is a rate, negotiated by the Scheme, with service provider groups e.g. hospitals and pathologists.
  • Network see DSP€.
  • Oncology a field of medicine that includes the treatment of cancer. It usually consists of chemotherapy or radiation therapy. Members need to register on the Cancer disease management programme and submit a treatment plan in order to obtain the benefits offered.
  • Overall Annual Limit the overall amount that a member and his dependants is allowed over a calendar year, in terms of the option and scheme rules. Any benefit remaining at year end cannot be carried forward.
  • Over the Counter Drugs (OTC) medication that is obtained from a pharmacy without a prescription. This includes unscheduled (S0) up to schedule 2 (S2) medication.
  • PMB Prescribed Minimum Benefits as set down 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 270 medical conditions (Declned in DTP) and 27 chronic conditions defined in the CDL. These costs may not be paid from the members savings. Cost saving measures can be used by way of appointing DSP’s, and by using Reference Pricing (RP) and Formularies.
  • Pre-authorisation A member must obtain prior approval for an intended admission to hospital or requiring other high cost services. 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 R2 500. Emergency treatment is not subject to Pre-authorisation but members should notify the scheme as soon as possible after the event.
  • Pre-existing Condition any condition for which medical advice, diagnosis and treatment was recommended or received within the twelve month period prior to application for membership.
  • Preferred Provider Network a group of preferred providers contracted to the scheme to deliver quality healthcare services and to participate in case management and cost effectiveness in terms of the scheme benefits.
  • Primary Healthcare Provider these providers can include GP’s, registered nurses, oral hygienists and Allied Health Care workers, dealing with the treatment of minor ailments or injuries.
  • Principal Ofïcer the person appointed by the Board of Trustees of a scheme to act as the Chief Executive of the scheme.
  • Pro-rated Benefits some benefits offered by a scheme are subject to an annual overall limit to which pro-rating may apply if you join after 1st January i.e., if your annual benefit is R5 000 and you joined the scheme in July your benefit for the remainder of the year would be R2 500.
  • Prosthesis a fabricated artificial substitute for a missing or diseased part of the body, which is surgically implanted either internally (artificial eye, cardiac stents, valves, etc.) or externally applied (artificial limb).
  • Protocol means a set of guidelines in relation to diagnostic testing and treatment for specific conditions and includes, but is not limited to, clinical practice guidelines, standard treatment guidelines and disease management guidelines.
  • Reference Pricing (RP) is the maximum price for which the Scheme will be liable for specific 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.
  • Rejection Codes the codes rejected on a member’s or service provider’s remittance advice indicating why an account has not been processed or not fully paid.
  • Related Account any account/claim, related to an approved in-hospital admission, other than the hospital account. In terms of CAMAF benefits, on most options the scheme provides cover for post hospital related accounts, to a maximum of 90 days.
  • Risk Contributions those funds allocated to the overall pool of funds for the payment of all claims other than those paid from the MSA.

    • Salary Total cost to company prior to deductions.
    • Scheduled drugs see Medicine schedule€
    • Self-payment Gap this is a gap in benefits between the level of MSA allowed and the point at which the scheme once again pays claims. CAMAF does not operate on the basis of MSA paying for Day to Day services and then imposing a self-payment gap followed by benefits being paid by the scheme  see MSA€.
    • SEP – Single Exit Price nationally applied pricing for medication as determined by the Department of Health and the pharmaceutical manufacturers or importers. This results in the actual cost of medication being the same no matter where in the country it is purchased; any difference in price is as a result of the dispenser’s mark up.
    • Spouse the person you are married to under any law or custom recognised by South African law.
    • Threshold where schemes pay day to day benefits from MSA, they set a threshold to be reached before the scheme pays for day to day benefits again. The threshold is the annual savings compenent plus a pre-determined self-payment gap – see illustration below:Day to Day Benefits
      Payment by scheme up to a pre-determined limit
      MSA for day to day benefits R7 000
      Self-payment gap (paid by the member) R5 000 Claims must continue to be sent to the scheme for accumulation toward the threshold but in some cases claims do not accumulate toward this threshold so the self-payment gap could be more than anticipated.
      Threshold R12 000

This does not apply to any CAMAF options.

 

  • TTO – To Take Out medication supplied by the hospital for use after the date of discharge from hospital limited to a 7 day supply.
  • Voluntary / Involuntary Use – when a scheme has an appointed DSP (Designated Service Provider) and a member voluntarily uses an alternative service provider there is usually a penalty imposed on such claims e.g., % co-payment or allocation to another benefit. If a member is in a position where they are unable to use the DSP because of an emergency or unavailability, this is regarded as involuntary use and is not normally subject to a penalty; motivation should be provided.
  • Waiting Periods in terms of the Medical Schemes Act, schemes are allowed to place waiting periods on members joining a scheme, due to risk factors that a member may pose to the scheme. These waiting periods take the form of:
    Condition specific waiting periods, which can be placed on a member for a maximum period of 12 months.
    General waiting period, which can be placed on a member for a period of 3 months, in which no claims will be paid other than for PMB conditions.

For more information, contact our Client Relations Telephone on
0860 100 545 or 011 707 8400
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