Overall annual limit Benefits must be authorised

Hospital accommodation
Ward fees, operating theatres, unattached theatres and day hospitals

Payable from MSA, thereafter from day-to-day pool - except for PMBs. Subject to pre-authorisation.

Treatment in lieu of hospitalisation
Registered step-down facilities, hospices, registered nurses and rehabilitation centres when hospitalisation is not clinically appropriate

Medicines
Dispensed and used in-hospital

Consultations, procedures and operations performed by registered medical specialists

Written referral required

Laparoscopic and endoscopic procedures performed in-hospital

Written referral required

General practitioner consultations and procedures

Any procedure performed by a General Practitioner requires pre-authorisation

Registered medical specialist consultations and procedures

Written referral required

Laparoscopic and endoscopic procedures

Written referral required

Maxillo-facial surgeons
In-hospital procedures

Written referral required 

Ante-natal consultations and foetal scans
In- or out-of-hospital

Provided by a registered gynaecological or radiology practice

Radiologist procedures, Angiograms, CT scans, duplex doppler scans, interventional radiology, MRI scans, and nuclear medical investigations

Written referral required

Black and white x-rays

 In-hospital

Mammogram benefit

Provided by a registered radiology practice

Bone density benefit

Provided by a registered radiology practice

Pathology services
in-and-out of hospital

With Pathcare and Lancet Laboratories who are SANAS-accredited

Written referral required

Prostheses and implants, excluding hearing devices and dental implants

Refer to Prostheses and Implants price list

Chronic medication Subject to authorisation

Access to the chronic medicine benefit is subject to CMP’s formularies and protocols. If you are diagnosed with a chronic condition, you will more than likely be required by your doctor to take regular medication. Although all our members receive cover for chronic conditions, it is not automatic: you will need to obtain pre-authorisation by first registering with our Chronic Disease Management programme. Once you are registered, you will only need to re-register if your medication changes, or if we request it for administrative purposes. The following conditions are covered, and make up our Chronic Disease List (CDL):

•  Addison’s Disease
•  Anti-coagulating therapy
•  Asthma
•  Bipolar Mood Disorder
•  Bronchiectasis
•  Cardiac failure
•  Cardiomyopathy
•  Chronic Obstructive Pulmonary Disease
•  Chronic Renal Disease
•  Coronary Artery Disease
•  Crohn’s Disease
•  Cushing’s Disease
•  Diabetes Insipidus
•  Diabetes Mellitus Type 1 & 2
•  Dysrhythmias
•  Epilepsy
•  Glaucoma
•  Haemophilia
•  HIV
•  Hyperlipidaemia
•  Hypertension
•  Hypothyroidism
•  Rheumatoid Arthritis/Juvenile Rheumatoid Arthritis
•  Multiple Sclerosis
•  Parkinson’s Disease
•  Schizophrenia
•  Systemic Lupus Erythematosis
•  Ulcerative Colitis

To register with the Chronic Disease Management programme, please contact our MRM division at 021 937 8300, or email chronic@cmp.co.za.

As with any medical scheme, we are unable to cover certain procedures, products and services. These are listed as exclusions across all our products and may never be paid for from insured benefits, subject to PMB rules. They may, however, be paid for from the MSA (HealthPact Silver and Select) if funds are available.The following exclusions apply:

•  Blepharoplasties, or any procedure to correct eye refraction errors including, but not limited to an excimer laser/Lasik
•  Treatment for sexual dysfunction (male and female)
•  Infertility treatment, unless authorised within PMB level of care criteria
•  Breast reductions, including scar revision, Botox, breast augmentation and gynaecomastia
•  Mammaprint genetic testing and any other type of genetic testing
•  Non-diseased breast reconstruction, nipple reconstruction and symmetry, unless authorised within PMB level of care
   criteria
•  Any cosmetic surgery
•  Long-term nursing care (such as frail care nursing)
•  Non-PMB treatment relating to alcohol or substance abuse, wilful self-injury or attempted suicide
•  Non-PMB psychological and psychiatric treatment, including sleep studies
•  Treatment and/or surgery for obesity
•  Educational and group therapy
•  Protective gear
•  Non-PMB treatment for HIV/AIDS
•  Treatment relating to or forming part of organ transplants that does not fall within the PMB level of care
   criteria
•  Non-PMB external devices (including crutches, commodes, nebulisers, pronator boots, bed pans, raised toilet seats,
   wheelchairs, and CPAP machines)
•  Non-PMB hearing devices and cochlear implants (or the maintenance thereof)
•  Artificial and synthetic blood products
•  Dental implants, orthodontic treatment, prosthodontic treatment, orthognathic procedures, periodontic treatment
•  General dentistry performed under general anaesthetic or conscious sedation for minor beneficiaries over the age of
   7 years
•  Experimental or unproven treatments, procedures, devices, unregistered medicines and Section 21 medicines, as per
   the Medicines Control Council
•  Household medicinal remedies, contraceptives, patent medicines, non-ethical and all proprietary preparations
   (including vitamins, supplements, minerals, medical creams, soaps, shampoos, and laxatives)
•  Medical examinations for insurance, school, association, emigration, visa, employment or other applications
•  Any treatments or costs not specifically provided for

Agreed tariffs. CMP has negotiated fixed tariffs with the major hospital groups in South Africa, namely Medi-Clinic, Netcare, Life Healthcare and National Hospital Network. These agreed tariffs, which are not necessarily linked to the CMP tariff, are applicable to all CMP members requiring hospitalisation. There are a few specific hospitals that don’t fall into these major groupings and in those instances, claims will only be paid at the CMP tariff, which may result in payment shortfalls.

Claims. All claims must be submitted within 4 months of the date of treatment. In order for members to claim reimbursement from CMP, the service provider must have an active Board of Healthcare Funders (BHF) practice number.

CMP tariff. This tariff represents the maximum amount CMP will pay to service providers on behalf of its members. The 2021 CMP tariff is the 2020 CMP tariff + 4.4%.

Co-payments. In some cases, a specific pre-determined amount of the cost of the procedure or service in question will be for members’ own account, as per our benefit rules. A co-payment is not the same as a payment shortfall.

Day-to-day benefits (HealthPact Silver only.) In addition to in-hospital benefits and an MSA, HealthPact Silver beneficiaries are allocated built-in, fixed and specified annual day-to-day benefits like two GP visits, separate dental cover and an acute medicine benefit. Unlike the MSA, any remaining built-in day-to-day benefits are not carried over to the following year.

Day-to-day pool. (HealthPact Select only.) At the beginning of each year, HealthPact Select beneficiaries are allocated a versatile and flexible pool of benefits to pay for day-to-day expenses. This day-to-day pool comes into effect once MSA funds are depleted. Unlike the MSA, any remaining day-to-day benefits are not carried over to the following year.

Dental procedures (in- and out-of-hospital). Dental work is only covered as per the CMP Dental Protocol.

Emergency services. If you need the use of emergency road transport services, you must obtain authorisation within 72 hours of the event and the service must be provided by a registered service provider.

Any airlifting services must be pre-authorised prior to take off.

In-excess tariffs. If a service provider charges in excess of the CMP tariff, CMP will reimburse the member.

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

Medical Savings Account (MSA). HealthPact Silver and Select members contribute to a compulsory MSA each month via their monthly contributions. The entire savings amount, which is equivalent to 12 monthly contributions, is pre-funded at the beginning of each year. The MSA will accrue interest.

The MSA may not be used to pay for PMBs or to offset contributions. If a member transfers to or from another medical scheme, the savings will be transferred accordingly. If a member resigns before the end of the year and has used the full pre-funded amount, CMP will claim back the portion of savings owing for the rest of the year. If a member dies, any savings will be transferred to the deceased member’s estate.

Payment of benefits. If a member requests that benefits are paid directly to them, we will oblige at our discretion. CMP reserves the right to withhold payment of claims referred to the HPCSA for investigation.

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

Precribed Minimum Benefits (PMBs). Prescribed Minimum Benefits (PMBs). PMBs are the minimum benefits that all medical schemes are legally required to cover so that members are always covered in life-threatening situations. A set of about 270 medical conditions, 29 chronic conditions, and all genuine emergency medical conditions are classified as PMBs. All PMBs are overseen by our internal PMB committee

PMBs will be paid in accordance with current legislation if services are obtained from a Preferred Provider, or involuntarily obtained from any other service provider. This condition is subject to pre-authorisation, as well as rules 17.9 and 17.10 (HealthPact Premium), 18.9 and 18.10 (HealthPact Silver) and 19.9 and 19.10 (HealthPact Select) of the full benefit sets.

Pro-rated benefits. Any member who joins CMP after 1 January will receive out-of-hospital benefits (day-to-day benefits/pool and savings, depending on the HealthPact plan in question) in proportion to the number of contributions they will pay for the remainder of the year.

Referral of accounts. If an account submitted to CMP appears to be invalid for whatever reason, we reserve the right to scrutinise the account and, if necessary, take further action on a member’s behalf. If necessary, the account will be referred to the HPCSA for further investigation. Until the grievance is resolved, CMP may withhold payment of that claim.

Referral to a specialist. In the interests of better co-ordinated care and the management of costs, members must have a written motivation from preferably their general practitioner (GP) or family physician before seeing a specialist, should they require any form of hospitalisation or procedure.

Registered practitioner. A registered practitioner is one who is registered with the Health Professionals council of South Africa (HPCSA). The HPCSA is a statutory body established to serve and protect the public and provide guidance to registered healthcare practitioners and medical schemes. Cover is subject to instruction by a HPCSA-registered medical practitioner (including a paramedic).

Cover is subject to services received from registered medical specialists, limited to anaesthetists, dermatologists, gynaecologists, paediatric cardiologists, paediatric surgeons, cardiothoracic surgeons, general surgeons, neurologists, neurosurgeons, otorhinolaryngologist (ear, nose and throat specialists), urologists, clinical haematologists, gastroenterologists, nuclear medicine practitioners, ophthalmologists, orthopaedic surgeons, physicians, plastic & reconstructive surgeons, and pulmonologists.

Single Exit Price (SEP). A SEP is the price charged for drugs by drug manufacturers to service providers (pharmacies, hospitals and practices for example). This price, as well as the dispensing fee charged by service providers, is regulated by government.

Supplementary services. This includes aromatherapists, chiropodists, chiropractors, dieticians, hearing aid acousticians, homeopaths, herbalists, naturopaths, occupational therapists, orthotists, orthoptists, physiotherapists, podiatrists, psychiatrists, psychologists, physical medicine practitioners, reflexologists, social workers, speeth therapists and sexologists. Separate authorisation is required for these services in-hospital and once you leave hospital, if associated with the hospital event.

Written referral. This is a referral from a registered General Practitioner or family physician. The referral must be in the form of a clinically appropriate medical report/referral letter. This report must indicate why a beneficiary needs to be referred, what conservative treatment has been followed and the beneficiary’s recent medical history. This is in accordance with rule 17.11 (HealthPact Premium), 18.11 (HealthPact Silver) and 19.11 (HealthPact Select).