Should you suspect the Scheme of conducting business in a fraudulent or unethical fashion, please report it via:

KPMG Ethics Hotline

Toll free: 0800 21 26 38

Email: ethicsline@kpmg.co.za

Fax: 0800 20 07 96

Email: fraud@lhh.co.za

These are the Prescribed Minimum Benefits that the Act says a medical scheme has to pay for, irrespective of the member’s available benefits. Medical schemes have to pay for the diagnosis and treatment of these conditions. There are 271 conditions that medical schemes have to pay for. These conditions include meningitis, tetanus, treatable cancer and many others. The Medical Scheme has to pay in full at cost, provided the member uses the designated service provider. If the member uses another service provider by their own choice, a co-payment may apply.
 

When joining a medical scheme as a new member, the new member must provide the scheme with a comprehensive medical history of them and their dependants. If a new member neglects to tell the scheme of certain pre-existing medical conditions, and then later on wants medical cover for these conditions, the scheme has the right to not pay for the medical diagnosis and treatment. In severe cases of non-disclosure, the scheme also has the right to cancel the person’s membership.

These are 27 chronic diseases that the government says a medical scheme has to pay for, irrespective of the medicine benefits the member has got left on his plan. For example, hypertension and asthma is classified as chronic diseases.

A chronic disease is a condition that is life-threatening, on-going and long-term. Government has created a set of minimum requirements that has to be met for a disease to be certified as a chronic disease. For example: If somebody is suffering from elevated cholesterol that can successfully be turned around by a lifestyle change, this condition will be paid from the member’s day-to-day benefits, and not the chronic disease benefit.

A member has to register for this benefit and benefits are awarded based on government protocols. Medication for these diseases is managed through a formulary. If the member does not register, the chronic medicine will be paid out of the normal medicine benefit.

Members have to get their chronic medicines from a designated service provider, otherwise co-payments might apply.

Members need to register with a scheme’s chronic disease service provider to qualify for chronic disease benefits. If they don’t, their chronic medication will be paid from their normal medicine benefits.
 

One of the legally provided tools that schemes can use to manage the cost of providing diagnoses and treatment for PMBs, is Designated Service Providers. A Designated Service Provider is a medical provider that a scheme has negotiated with to provide healthcare for PMB and CDL treatment. By using the scheme’s designated service provider, members contribute to the effective use of the scheme’s cash reserves, and members’ co-payments and levies are reduced.

Next Generation™ products are simple! These products provide the balance between product, price, membership and health status. These products afford members the opportunity to take responsibility for the management of their day-to-day healthcare spend and, at the same time take, ownership of their personal healthcare needs. SPECTRAMED's Next Generation™ products offer members access to a personal medical savings account called My Saver™ to pay for their day-to-day expenses. With My Saver™ members can save the money in their savings account, should they not need to use it. Any positive balance in the account remains the member's money and this balance earns interest. On the top two SPECTRAMED benefit options (SPECTRA Cobalt and SPECTRA Azure), certain day-to-day expenses will be covered by the Scheme from the Benefit Booster™ and not from the member's My Saver™. The Benefit Booster™ and My Saver™ operate independently.

SPECTRAMED's Next Generation™ benefit options do not expose members to the complexities attached to thresholds or self-funding gaps. Many medical schemes in the industry provide their members complicated benefits that, more often than not, leave members confused and frustrated and with high out-of-pocket medical expenses.

A beneficiary is anybody who belongs to a medical scheme. Therefore beneficiaries are members, adult and child dependants. A beneficiary, therefore, is not necessarily the ‘paying member’. Some schemes also refer to their beneficiaries as "lives covered."

For example: "Family of four: Main member, adult dependant and 2 child dependants" means that in that group there is 1 member, but 4 beneficiaries.
 

A member is somebody who belongs to a medical scheme and who pays the monthly contribution.

Medical schemes are allowed to impose waiting periods on new members, except in cases where:

• a baby is born during the membership;
• the member changes the option plan they’re on, or
• somebody joins the scheme due to change of employer or employer changing schemes.

There are 3 categories of underwriting: 

Condition-specific waiting periods

These are specific conditions a scheme is legally allowed to exclude to qualify for treatment for a period of 12 months.
 

3rd Party Service Providers are contracted by schemes to fulfil certain administration functions. These functions include:

• Claims administration – submission, approval and payment of claims;
• Hospital authorisations;
• HIV/AIDS managed care providers;
• Optical care providers;
• Chronic Disease Management.  

SPECTRAMED has a share-source business model, which means that we only outsource functions to contracted 3rd party service providers - if they can provide a better service and better product at a better price. By employing this business model, SPECTRAMED has managed to reduce administration costs to less than 10% of annual gross contributions.
 

All the SPECTRAMED benefit options except for SPECTRA Aqua features a personal medical savings account called My Saver™. Your My Saver™ works almost like an advance from the Scheme. You will pay a monthly My Saver™ contribution as part of your total monthly contribution due to the scheme. However, you will have immediate access to the full My Saver™ allowance upfront for 12 months.

The My Saver™ contribution is a fixed percentage (%) of your total monthly medical scheme
Contribution.

SPECTRA Cobalt: 25%
SPECTRA Azure: 20%
SPECTRA Capri: 15%
SPECTRA Cyan: 15%
SPECTRA Aqua: No My Saver™
 

My Saver™ amounts accumulate
The money in your My Saver™ Account remains your money and if you have not used any of it at the end of the year, the money will be carried forward to the next year. This will enable you to take responsibility for you and your family’s day-to-day healthcare needs as well as manage your healthcare spend accordingly.
 

On the SPECTRA Cobalt and SPECTRA Azure Benefit Options, a Benefit Booster™ will cover certain day-to-day benefits and will be paid for by the Scheme, which means your My Saver™ balance will remain unaffected.

For SPECTRA Cobalt, Benefits included in the Benefit Booster™ are Screening Benefits; Specialised Dentistry; Psychiatric Treatment; Optical Benefits; External Prostheses and Appliances.

On SPECTRA Azure the Benefit Booster™ includes Screening Benefits, Psychiatric Treatment and Specialised Dentistry.
 

When submitting a claim, it has to be submitted with the correct account or statement.
The following details have to be on the submitted claim (invoice):

• Name and membership number of the member.
• Who was treated, for example, dependant or main member?
• Name of the supplier or service.
• The final date the service was rendered.
• The total amount charged for the service.
• Tariff amount covered by the Scheme.
• Practice number.
• ICD 10 code.
• Claim (invoice) to be signed by member.

The claim has to be submitted no later than the last day of the 4th month following the month in which the service was rendered.

Members can submit their claims by using a variety of methods:

• E-mail scanned copy of the invoice to enquiries@spectramed.co.za
• By post to Private Bag X1, Gardenview, 2047.
• By fax to 0861 492 492.

Your monthly contribution is calculated based on:

• The option (plan) you choose;
• Your income bracket;
• The size of your family.

Schemes will sometimes have co-payments that members have to pay on certain elective surgical procedures, as well as medicine co-payments. Members and the Scheme, in many ways, are in a partnership, which aims to protect the interests of all the members. Unfortunately, some members see member funds as their personal kitty, and these members need to be incentivized to question their service provider on alternative, more cost-effective treatment options available to them.
 

What is a late-joiner penalty and how is it calculated?

One of the regulations of the Medical Schemes Act is that someone can get penalized for joining a medical scheme only late in life. These members are called ‘late joiners’.
A late joiner is any person older than 35 years that has never belonged to a medical scheme before. A person that is older than 35, but joined a South African Medical Scheme before 1 April 2001 and has been on a medical scheme without a longer than 3-months break in coverage, is excluded from late joiner penalties.

In other words, no late joiner penalty can be imposed if you are:

• Under the age of 35;
• If you joined a medical scheme before 1 April 2001;
• If you have had less than a 90-day break between different medical schemes.

A late joiner penalty is calculated the following way:
Penalty Band = Age of new member – (35 + the number of years of proven medical scheme membership).

The answer to this calculation will put you in 1 of 4 categories:

A late joiner penalty stands until you stop being a member. It doesn’t matter which medical scheme you choose, if you qualify to be a late joiner, you will still pay a late joiner penalty as per the Act.

The SPECTRAMED tariff is aligned to include the following relevant tariffs:

• NHRPL - National Health Reference Price List, as published by the Department of Health (DoH)
• SEP - Single Exit Price for medicine, plus the relevant dispensing fees.
• Negotiated tariff - pre-negotiated rate for certain healthcare services that is provided by different service providers. This negotiated tariff is based on arrangements that the Scheme has made with specific service providers.
• Designated Service Provider Tariff - a rate the Scheme pays to contracted service providers to provide designated (specific) services and costs.
• Preferred Provider Tariff - a rate the Scheme pays to a pre-determined group of service providers who have entered into preferential service, cost and clinical outcome arrangements with the Scheme.

There are 3 ways in which you can register for a chronic condition:

• Get your doctor or pharmacy to phone us on 0860 119 553 with your script.

OR

• Phone us yourself with the following information in hand: 

1. Your script;
2. The conditions the script is treating;
3. The medical name of the prescribed medication;
4. The prescribed dosage, for example 20 mg, 40 mg and so forth.

OR

• E-mail your script to spectramed@mediscor.co.za and allow 3 working days for the registration to be activated.

You have to re-register every year for the benefit to stay active.

Phone EuropAssist, a 24-hour operation, on 0800 773 2872, and they will assist you on the spot.

All specialised dentistry treatment has to be pre-authorised. Click here to download the applicable Specialised Dentistry application form.

Your dentist / dental surgeon needs to complete the application form, which you then need to e-mail to dentalauthorisations@spectramed.co.za or fax to 011 259 7243. You need to have the following information completed on this form:
 

• Membership number.
• Dependant’s name and date of birth.
• Service provider’s practice name and –number.
• Anaesthetist’s practice name and –number, if sedation is being done in the doctor’s rooms.
• Clinical codes.
• Tariff amounts.
• Tooth number – if applicable.
• Copy of laboratory invoice – if applicable.
• Clinical motivation for the proposed treatment.
• In case of a denture motivation, you need to supply the mouthpart number, e.g. top or bottom dentures.
• In case of orthodontic treatment, we always require the ceph tracing, photos, x-rays, and clinical motivation for the treatment.

To get authorisation for any hospital admission:

• Phone MSO on 0860 102 474 or
• Send an e-mail to preauth@mso.co.za

Make sure you have the following information ready when you apply for authorisation:

• Your membership number.
• Name and date of birth of the patient.
• Your contact details.
• Date of admission and the proposed date of the operation or procedure.
• Reason for admission and applicable procedure codes.
• Name of the doctor and his/her telephone and practice numbers, if available.
• Name of the hospital, telephone and practice number, if available.

How to get authorisation for in-hospital dentistry (specialised dentistry in- and out of hospital):

• Phone Vmed on 0861 497 497

Make sure you have the following information ready when you apply for authorisation:

• Your membership number
• Name and date of birth of the patient
• Your contact details

The following information needs to be supplied on the application form, but is not necessary for the call centre agent:

• Date of admission and the proposed date of the operation or procedure
• Reason for admission and applicable procedure codes
• Name of the dental practitioner and his/her telephone and practice numbers, if available
• Name of the hospital, telephone and practice number, if available.

If you have to be admitted to hospital in an emergency, you can go to hospital without getting authorisation beforehand. Just make sure to get authorisation for your hospital admission as soon as possible.

To get authorisation for any hospital admission:

• Phone MSO on 0860 102 474 or
• Send an e-mail to pre-auth@mso.co.za

Make sure you have the following information ready when you apply for authorisation:

• Your membership number.
• Name and date of birth of the patient.
• Your contact details.
• Date of admission and the proposed date of the operation or procedure.
• Reason for admission and applicable procedure codes.
• Name of the doctor and his/her telephone and practice numbers, if available.
• Name of the hospital, telephone and practice number, if available.

All medical schemes require their members to get authorisation for any in-hospital treatment. If a member does not get authorisation, the Scheme can refuse to pay the bills. All authorisations are based on an ICD10 code, which includes a clinical protocol for the proposed treatment. In case of a life-threatening medical emergency admission, most schemes will give you up to 48 hours from the incident to apply for authorisation. In some cases where specialized dentistry is required, such as crowns or dentures, some schemes may require a clinical motivation from the dental surgeon, as well as authorisation prior to the procedure being done.

In short, a formulary is a list of scheme-approved medicines for a specific condition. Formularies may differ from scheme to scheme and may also differ between options.
These drugs listed on the formulary are selected based on proven clinical efficiency and cost-effectiveness. Members still have the ‘freedom’ to choose a drug set outside of the formulary; however, this would lead to a higher levy or co-payments for the member.
 

NAPPI is the abbreviation for National Pharmaceutical Product Interface, and is a national standard.

Any given ethical, surgical and consumable product can be uniquely identified by the NAPPI code. Service providers and medical schemes are able to identify the item and the price by using the NAPPI code.

The NAPPI code is a 9-digit code and contains the following information:

• product description;
• strength;
• pack size;
• manufacturer.

The first 6 digits describe the product and the 3-digit suffix describes the pack size. This means that if an item has different pack sizes, the first 6 digits are the same, but the 3-digit suffix differs. A range code is allocated to surgical items, which have different sizes but are priced the same. An example is Foley Catheters - these come in different sizes, but cost the same.

NAPPI codes are specific to the manufacturer / importer. Each manufacturer must apply for NAPPI codes for his items. A third party, such as a price file vendor, cannot apply for a NAPPI code on behalf of the manufacturer.

ICD stands for the International Classification of Diseases. In other words, any medical treatment given to a person has to have an ICD 10 code, which will indicate to the scheme what the member is being treated for.