Agreed tariff (AT)

CMP has negotiated a fixed tariff with the four major hospital groups in South Africa - Medi-Clinic, Netcare, Life Healthcare and National Hospital Network. This agreed tariff, which is not necessarily based on the NHRPL tariff, is applicable to all CMP members requiring hospitalisation.

Beneficiary

Each principal member and each dependant is listed as an individual member of CMP. Each of these members is a recipient of scheme benefits, and is therefore known as a beneficiary.

Benefit year

The benefit year runs from January to December. If a member joins at any time after January, their benefits will be pro-rated for the remainder of the benefit year.

Benefits

Benefits are essentially what you, as a medical aid member, are covered for and receive in return for your monthly contributions. CMP's three plans each include a varying degree of scheme-specific cover for in-hospital and day-to-day expenses - these are your benefits.

Branded medicine

When a drug is first developed and patented by a pharmaceutical company, it is named by the company and may be produced only by its originator. Once the patent has expired, however, competitor companies often develop generic equivalents of the branded medicine in question.

Capitation

This healthcare model comes into effect when a fixed amount of money is paid to a network of healthcare providers by a managed care organisation. The up-front payment translates into cost savings for scheme members. The opposite of a capitation model is a fee-for-service model, which is based on money paid to a service provider as and when the service is supplied.

Case management

CMP has taken various steps to contain the costs of certain conditions and forms of treatment. This process is known as case management, or medical case management (MCM). To enable effective case management, we rely on a network of preferred service providers, which in turn saves money for all our members. Pre-authorisation, as well as ongoing advice to members about cost-effective treatment, is another integral part of the case management process.

Chronic conditions

These medical conditions, diseases or illnesses are best described as ongoing, or recurrent, and life-threatening. Unfortunately, chronic conditions usually require prolonged medical treatment and monitoring as a life-sustaining measure.

Chronic Disease List (CDL)

A list of about 29 chronic conditions is published by our regulator, the Council for Medical Schemes. By law, all conditions named on this Chronic Disease List (CDL) must be treated according to the rules of Prescribed Minimum Benefits, as well as our formularies.

Chronic medication

When a patient is diagnosed with a chronic condition, a doctor will prescribe medication as a course of treatment. This chronic medication is medication needed on an ongoing basis, and for at least three months.

Chronic medicine benefit

As part of the insured portion of each of our plans, we allocate benefits to specifically cover chronic medication. The extent of this chronic medicine benefit varies from plan to plan, and is subject to pre-authorisation.

Claim

Once a member has paid for medical products or services, they may send the receipt to CMP for reimbursement within four months of the date of service. Once the claim is received, and if all the details are correct, we will process and pay out the claim accordingly. A medical practitioner who is contracted in to medical schemes may claim directly from us on a member's behalf.

Claims paying ability

The number of monthly claims that a medical aid is able to cover with its existing cash and cash equivalents is referred to as its claims paying ability.

CMP case management protocols

The provision of certain benefits are subject to pre-authorisation and confirmation from our MRM division. These CMP case management protocols ensure that members receive appropriate treatment for their age and condition.

CMP tariff

As with every medical scheme, CMP has calculated its own medical scheme rate (MSR). The CMP tariff, which is the maximum amount CMP will pay for products and services, is equivalent to the 2010 CMP tariff + 7%.

Co-payment

Occasionally, members will need to contribute specific, pre-determined amounts for certain medical procedures. These amounts are called co-payments. An example of a co-payment is the R1,000 payable on all laparoscopic and endoscopic procedures.

Community rating

Once a scheme puts a price on a specific plan or product, all members must be charged the same rate for that medical cover, regardless of their age or health. This principle is known as community rating.

Comprehensive cover

Any form of medical insurance that covers you across a range of instances is considered to be comprehensive. A typical example of comprehensive cover is a plan that offers in-hospital and out-of-hospital benefits. A stand-alone hospital plan, for example, does not offer comprehensive cover.

Condition-specific waiting period

As part of the underwriting process, new members may have one of two waiting periods imposed on them on joining. A condition-specific waiting period prevents new members from claiming for costs associated with a pre-existing medical condition for a set period of time. The waiting period can be for up to 12 months, after which, the condition will be covered as per CMP's benefit sets.

Consultation

Any visit to a medical service provider like a doctor, specialist or physiotherapist is called a consultation.

Contracted in

If a medical practice is contracted in, it means that their fees are on par with the NHRPL/CMP tariff, as recommended by the Council for Medical Schemes. Practices that are contracted in may also claim directly from us on behalf of a member.

Contracted out

If a medical practice is contracted out, it means that their fees are higher than the NHRPL/CMP tariff. If a member visits a practice that is contracted out, CMP will only cover up to the NHRPL/CMP tariff, as recommended by the Council for Medical Schemes.

Contribution

In exchange for the benefits specified on a chosen plan, a member pays a fixed amount to CMP each month. This contribution, which varies according to the number of dependants as well as the plan, is then pooled and used to pay out member claims.

Council for Medical Schemes (CMS)

This statutory body was established by Parliament to supervise and regulate all medical schemes in South Africa. In turn, the Council for Medical Schemes (CMS) is governed by a board appointed by the Minister of Health.

Credit rating

An international company called the Global Credit Rating (GCR) is tasked to rate a medical scheme’s ability to pay out claims. Hospitals are also subject to a credit rating, which determines their ability to pay for and render services.

Day-to-day benefits

In addition to in-hospital benefits and an MSA, HealthPact Silver beneficiaries are allocated selected annual day-to-day benefits like two GP visits, separate dental cover and an acute medicine benefit. Unlike the MSA, any remaining day-to-day benefits are not carried over to the following year. Benefits are pro-rated if a member joins the Scheme. 

Day-to-day pool

At the beginning of each year, HealthPact Select beneficiaries are allocated a flexible pool of benefits to pay for day-to-day expenses. This day-to-day pool comes into effect once MSA funds are depleted. Adult beneficiaries receive R4,800 per year, while minor beneficiaries receive R1,200 per year. Unlike the MSA, benefits remaining at the end of the year are not carried over to the following year. 

Deductible

A specified list of costly medical procedures require a set co-payment from members. The amount is called a deductible, and must be paid up-front by a member prior to the procedure.

Dependants

When a family joins CMP, any immediate family member supported by the principal member is listed as a dependant. Dependants can include a spouse, parent or child. The principal member is responsible for paying a dependant's membership fees.

Disease management

CMP has adopted a holistic approach to healthcare to help members manage the implications of living with a serious disease. Disease management varies from case to case, but can include the provision of cost-management advice, counselling, education and Medical Case Management (MCM). Members are also sometimes required to register on scheme-specific programmes to access benefits.

Elective surgery

To preserve the funds of its members, non-essential, planned or optional surgery that is not life-threatening is not covered by CMP. An example of elective surgery is anything of a cosmetic nature, like breast augmentation.

Exclusions

There is a defined list of products, procedures and conditions that are not covered by CMP. This list of exclusions includes toiletries, cosmetic surgery and treatment for self-inflicted injuries, among others.

Family

If a principal member and one or more dependants join CMP, they are listed as a family. Depending on the chosen plan, certain benefits are pooled per family, while others are provided per beneficiary.

Formulary

For each of our plans, as well as for PMBs, CMP maintains a detailed list of medical conditions and a choice of suitable medicines for treatment. Because CMP will only cover medication listed on this formulary, we recommend that doctors only prescribe corresponding medication to help members avoid an unnecessary co-payment.

General waiting period

When a new member joins CMP, a standard three-month waiting period could apply to all listed beneficiaries. During this general waiting period no claims - other than for emergencies - will be paid.

Generic medicine

Once the patent on a brand-name drug expires, pharmaceutical companies are allowed to manufacture medicines using exactly the same ingredients. These generic medicines are of the same high quality as their brand-name counterparts, and have the same effect, but are significantly cheaper.

Global Credit Rating (GCR)

This international credit rating company is tasked with rating a medical scheme’s ability to pay out claims. Hospitals are also subject to the Global Credit Rating (GCR) system, which determines their ability to pay for and render services.

Hospice

When treatment is no longer effective, many people turn to these organisations to provide care to the terminally ill. At CMP, we cover hospice accommodation in lieu of hospitalisation across all our plans, subject to CMP conditions and pre-authorisation.

Hospital plan

Unlike comprehensive cover, a hospital plan covers only the major cost of hospitalisation and related procedures and does not make provision for day-to-day expenses; these plans are best suited to healthy individuals wanting cover for major events.

ICD-10 code

In 1996, the Department of Health adopted this international coding system to help with the identification and treatment of medical conditions. All known medical conditions have their own specific ICD-10 code. Medical practitioners are required to stipulate these codes with every procedure or prescribed course of treatment.

Inception date

An inception date refers to the date on which a member and his/her dependants were first registered as members of their medical aid.

Insured benefits

The basis of all our healthcare plans is grouped sets of limited benefits to cover specific areas of medicine. These insured benefits, which are paid out in relation to specific conditions or procedures, are renewed at the beginning of each benefit year. In contrast, a Medical Savings Account (MSA) is the non-insured portion of a plan. When insured benefits are exhausted, available savings are sometimes used to make up costs.

Late joiner penalty

If a new member is over the age of 35 on joining, and has not belonged to a scheme for up to two years prior, they might be charged an additional fee. This late-joiner penalty is calculated based on the number of years the new member has not belonged to a scheme, and added to monthly premiums for the duration of membership. The penalty is only applied to the insured portion of a member's benefit.

Managed healthcare

CMP has adopted a holistic approach to healthcare, which ensures the cost-effective and appropriate use of resources. As part of the managed healthcare approach, doctors, specialists and case managers work together to decide on the most cost-effective treatment programme for high-cost cases. 

Maternity

This term is used to describe any aspects of pregnancy or becoming a mother. For example, CMP offers plan-dependent maternity benefits to cover the medical costs of having a baby, subject to registering on our Mum's the Word programme.

Medical Case Management

As part of our managed-care approach to healthcare, CMP has taken various steps to contain the costs of certain conditions and forms of treatment. We have negotiated and partnered with specific service providers, saving money for all our members. Pre-authorisation is another aspect of medical case management (MCM), as is our dedication to establishing and advising members on cost-effective, yet appropriate, treatment. All these functions are overseen by our Member Relations Management (MRM) division.

Medical emergency

This term refers to the sudden, unexpected onset of a health condition that requires immediate medical attention. Where treatment is not available in a medical emergency, serious harm or even death could result.

Medical Savings Account (MSA)

Funds in a member's medical savings account (MSA) are built into monthly member contributions and allocated to the member at the beginning of each benefit year. They can then be used to cover various day-to-day expenses, excess tariff payments and elective procedures among others. At CMP the MSA is only available on HealthPact Silver and HealthPact Select.

Member

Any person (principal members and all dependants) who is registered with CMP, and who pays a monthly contribution in exchange for scheme benefits, is listed individually on our system as a member. Each member receives an equal amount of cover, as per their plan specifications.

Member contributions

In exchange for the benefits specified on a chosen plan, a member pays a fixed amount to CMP each month. These member contributions, which vary according to the type of member as well as the plan, are then pooled and used to pay out member claims.

Minor

Any dependant under the age of 21 years will be listed as a minor beneficiary.

NAPPI code

The National Pharmaceutical Product Interface (NAPPI) code system is used by the medical industry to identify various drugs. Each drug available on the market is assigned its own NAPPI code.

Non-healthcare expenses

In contrast to money spent specifically on the health of its members, non-healthcare expenses are usually administrative in nature. CMP has limited its non-healthcare expenditure by cutting out brokers and administrators and performing both these functions in-house.

Oncology

This field of medicine relates to the research, diagnosis and treatment of cancer. Examples of traditional oncology treatments include chemotherapy, radiation therapy and laser treatment among others. All benefits in respect of approved oncology/cancer treatment may be paid to the member directly, and not to the treating oncologist.

Option

CMP has designed three healthcare products to cater for the diverse medical needs of individuals, families or groups. Each option, or plan, differs in terms of benefits offered and contribution rates.

Out-of-hospital benefits

In addition to hospital benefits, some medical aids also provide plan-specific cover for products and services offered outside of hospitals. These out-of-hospital benefits form part of a plan's insured benefit.

Paediatrics

This specialised area of medicine deals with the medical care of infants, children, and adolescents up to the age of 14. A medical practitioner who specialises in paediatrics is called a paediatrician.

Patented medicine

When a drug is first developed and patented by a pharmaceutical company, it is named by the company and may be produced only by its originator. Once the patent has expired, however, competitor companies often develop generic equivalents of the patented medicine in question.

Pharmacist Advised Therapy (PAT)

Instead of the patient having to pay for a costly doctor's consultation, a pharmacist is often able to advise on the treatment of common ailments. Any treatment, medication or advice received from pharmacists is referred to as Pharmacist Advised Therapy (PAT).

Plan

CMP has designed three healthcare products to cater for the diverse medical needs of individuals, families or groups. Each plan, or option, differs in terms of benefits offered and contribution rates.

Pre-authorisation

With the exception of medical emergencies, all planned medical procedures (including prostheses) are subject to CMP case management protocols and to obtaining pre-authorisation in writing prior to the event. Members will be required to sign the accepted quote. In the case of medical emergencies, pre-authorisation will still be compulsory, and must be requested within 72 hours of the incident. Any medical treatment that extends beyond what is described in our formularies and protocols may result in a co-payment. To help protect our members from over-inflated prices, protocols and authorisations are prescribed by our Member Relations Management (MRM) division, who make sure that members receive the best care at reasonable rates. This is done by guiding members through the correct procedures to follow when dealing and negotiating with selected service providers, and by making sure that the best course of treatment is followed for the diagnosed condition. To obtain pre-authorisation, please call 0860 100 512 or email mrm@cmp.co.za during office hours. 

Pre-funded benefit

At the beginning of each benefit year, in January, certain benefits are made available to members in advance. Any pre-funded benefit, like a member's Medical Savings Account (MSA), is then contributed to by the member, via their monthly member contributions, throughout the year.

Pre-quote

For any planned procedure that requires pre-authorisation, members are asked to obtain a cost estimate from their treating practitioner before the event. This pre-quote system is CMP's way of controlling unnecessary spending of members' funds, and also guarantees members and practitioners of payment, provided the rules of the scheme are adhered to.

Preferred Provider

To help contain costs, CMP has negotiated with selected healthcare partners, also known as Preferred Providers, to provide approved medical products and services at pre-agreed tariffs. Clicks Pharmacy, for example, is CMP's Preferred Provider for chronic medication.

Prescribed Minimum Benefits (PMBs)

By law, all medical schemes are required to provide a minimum amount of medical cover to their members. These Prescribed Minimum Benefits (PMBs) ensure that members will always be covered for life-threatening conditions. Specifically, a set of about 270 medical conditions, 29 chronic conditions and all emergency medical conditions are classified as PMBs. PMBs will be covered, subject to pre-authorisation.

Principal member

The person who is listed as the main member or head of a particular family is known as the principal member. The principal member will more than likely initiate membership with the scheme, and remains responsible for the payment of member contributions for themselves as well as any dependants for the duration of the membership.

Private hospital

Unlike state hospitals, private hospital groups like Medi-Clinic are run as businesses. They are not reliant on government funding, and offer superior facilities and more immediate access to private practitioners. Due to higher overhead costs, however, private hospital admissions do cost more than state hospitals.

Pro-rata benefits

If a member joins the scheme after 1 January, benefits will be allocated as a percentage of a full year's benefits. In particular, pro-rata benefits will apply to pre-funded benefits (or those that have an annual limit), and will be calculated according to the number of months left in the year.

Protocols

To help contain costs, we rely on a set of treatment guidelines, compiled by medical experts, with regard to the effective treatment of specific medical conditions. We advise that our protocols, which differ from plan to plan, be followed by medical practitioners when treating patients to ensure the payment of benefits.

Public sector

Each provincial government in South Africa funds and maintains a system of publically accessible hospitals. Unfortunately, the hospitals within this public sector, also known as state hospitals, have earned a reputation of offering sub-standard facilities. Private hospitals, which are only accessible to high-income earners or members of medical schemes, are the alternative.

Radiology

This area of medicine uses advanced imaging technology to diagnose and treat various diseases. Well-known forms of radiology include X-rays, CT scans and MRI scans.

Reference pricing

CMP has set a maximum rand value that we will pay for a particular class of drug. This reference pricing is calculated by comparing the price of brand-name medication to available generic equivalents.

Restrictions

Depending on a new member's risk profile, they are sometimes subject to underwriting limitations. Restrictions can take the form of late-joiner penalties, waiting periods or exclusions.

Service provider

Anyone who provides medical advice, products or services is known as a service provider. Doctors, dentists, pharmacists, nurses and hospitals are all examples of healthcare service providers.

Shortfall

When there are not enough insured benefits or savings to pay for a medical account, the amount owing is called a shortfall. This often happens when a service provider charges more than what a member’s product provides for. A shortfall may be paid for from a member's medical savings account (MSA). But if savings are depleted, members become personally liable for the amount.

Single Exit Price

The price charged by drug manufacturers to service providers for their drugs is called Single Exit Price. This price, as well as the dispensing fee charged by service providers, is regulated by Government.

Solvency ratio

All medical schemes are legally required to maintain a minimum of 25% of all annual member contributions in their reserves at all times. This solvency ratio, which largely determines a scheme's financial sustainability, should be enough to pay out all member claims at once should the unlikely need arise.

Specialist

Medical practitioners who offer specialised products or services not offered by general practitioners (GPs) are called medical specialists. A specialist is more qualified to give an accurate diagnosis of a complex condition. When we refer to specialists, and cover for specialists in particular, we mean anaesthetists, dermatologists, gynaecologists, paediatric cardiologists, paediatric surgeons, cardio thoracic surgeons, general surgeons, neurologists, neurosurgeons, otorhinolaryngologists (ear, nose & throat), urologists, clinical haemotologists, gastroenterologists, nuclear medicine practitioners, ophthalmologists, orthopaedic surgeons, physicians, plastic & reconstructive surgeons and pulmonologists.

State hospital

Each provincial government in South Africa funds and maintains a system of publically accessible hospitals. Unfortunately, these state hospitals have earned a reputation of offering sub-standard facilities. Private hospitals, which are only accessible to high-income earners or members of medical schemes, are the alternative.

Supplementary services

On HealthPact Silver and Select, cover is available for selected additional medical services (subject to available MSA/day-to-day pool). These supplementary services include aromatherapists, chiropodists, chiropractors, dieticians, hearing aid acousticians, homeopaths, herbalists, naturopaths, occupational therapists, orthotists, orthoptists, podiatrists, psychiatrists, psychologists, physical medicine practitioners, reflexologists, social workers, speech therapists and sexologists.

Underwriting

Depending on a member's risk profile, restrictions are sometimes imposed in the form of waiting periods, late-joiner penalties or exclusions. This process is known as underwriting.

Waiting period

Depending on a new member's risk profile, restrictions limiting a member's ability to claim may be applied. One such restriction might be a waiting period, which may either be general (for three months) or condition-specific (for up to twelve months).