Member contributions 2021
|
HEALTHPACT PREMIUM |
HEALTHPACT SILVER |
HEALTHPACT SELECT |
|
Hospital cover only |
Hospital cover with Medical Savings Account (MSA)
|
Hospital cover with day-to-day benefits and Medical Savings Account (MSA)
|
Principal member |
R2,408 |
R2,402 (including R300 savings per month) |
R6,834 (including R300 savings per month) |
Adult beneficiary |
R2,408 |
R2,402 (including R300 savings per month) |
R6,834 (including R300 savings per month) |
Minor beneficiary |
R425 |
R360 (including R45 savings per month) |
R1,105 (including R49 savings per month) |
Medical Savings Account (MSA)
|
None |
Compulsory savings included in contribution |
Compulsory savings included in contribution |
> Hospitalisation
|
HEALTHPACT PREMIUM |
HEALTHPACT SILVER |
HEALTHPACT SELECT |
Overall annual limit Benefits must be authorised |
Unlimited Authorised admissions to hospital |
Unlimited Authorised admissions to hospital |
Unlimited Authorised admissions to hospital |
Hospital accommodation Ward fees, operating theatres, unattached theatres and day hospitals |
Up to 100% of the CMP tariff or Agreed Tariff in intensive care, specialised intensive care, high care and general wards. Subject to pre-authorisation. |
Up to 100% of the CMP tariff or Agreed Tariff in intensive care, specialised intensive care, high care and general wards. Subject to pre-authorisation. |
Up to 100% of the CMP tariff or Agreed Tariff in intensive care, specialised intensive care, high care and general wards. Subject to pre-authorisation. |
Emergency room treatment only Outpatient services |
No cover, except for PMBs |
Payable from MSA - except for PMBs |
Payable from MSA, thereafter from day-to-day pool - except for PMBs |
Hospitalisation/ institutionalisation for treatment of mental illness, alcoholism and drug addiction |
No cover, except for PMBs. Subject to pre-authorisation. |
Payable from MSA - except for PMBs. Subject to pre-authorisation. |
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 |
100% of CMP tariff for hospices and registered nurses, limited to 15 days per beneficiary. Subject to pre-authorisation. |
100% of CMP tariff for hospices and registered nurses, limited to 15 days per beneficiary. Subject to pre-authorisation. |
100% of CMP tariff for hospices and registered nurses, limited to 15 days per beneficiary. Subject to pre-authorisation. |
Emergency services Provided by a registered ambulance service |
100% of CMP tariff - except for PMBs. Subject to pre-authorisation. |
100% of CMP tariff - except for PMBs. Subject to pre-authorisation. |
100% of CMP tariff - except for PMBs. Subject to pre-authorisation. |
Blood transfusions In-hospital |
100% of cost to a maximum of 100% of CMP tariff. Subject to pre-authorisation. |
100% of cost to a maximum of 100% of CMP tariff. Subject to pre-authorisation. |
100% of cost to a maximum of 100% of CMP tariff. Subject to pre-authorisation. |
Materials and devices Used in-hospital |
100% of cost to a maximum of Single Exit Price/Agreed Tariff/pre-authorised tariff. Subject to pre-authorisation. |
100% of cost to a maximum of Single Exit Price/Agreed Tariff/pre-authorised tariff. Subject to pre-authorisation. |
100% of cost to a maximum of Single Exit Price/Agreed Tariff/pre-authorised tariff. Subject to pre-authorisation. |
Medicines Dispensed and used in-hospital |
100% of cost, up to the Single Exit Price for approved medicines. Subject to pre-authorisation. |
100% of cost, up to the Single Exit Price for approved medicines. Subject to pre-authorisation. |
100% of cost, up to the Single Exit Price for approved medicines. Subject to pre-authorisation. |
Supplementary services eg. physio, occupational, speech therapists and dieticians
|
100% of CMP tariff. Subject to pre-authorisation. |
100% of CMP tariff. Subject to pre-authorisation. |
100% of CMP tariff. Subject to pre-authorisation. |
Consultations, procedures and operations performed by general practitioners |
200% of CMP tariff. Subject to pre-authorisation. |
100% of CMP tariff. Subject to pre-authorisation. |
200% of CMP tariff. Subject to pre-authorisation. |
Consultations, procedures and operations performed by registered medical specialists
Written referral required |
200% of CMP tariff. Subject to pre-authorisation. |
100% of CMP tariff. Subject to pre-authorisation. |
200% of CMP tariff. Subject to pre-authorisation. |
Laparoscopic and endoscopic procedures performed in-hospital
Written referral required |
200% of CMP tariff. Laparoscopic procedures as per the endoscopic surgeon’s guidelines with a co-payment per scope, per procedure (co-payments are the same across all three plans – click here to view them in a pop-up window). Subject to pre-authorisation. |
100% of CMP tariff. Laparoscopic procedures as per the endoscopic surgeon’s guidelines with a co-payment per scope, per procedure (co-payments are the same across all three plans – click here to view them in a pop-up window). Subject to pre-authorisation. |
200% of CMP tariff. Laparoscopic procedures as per the endoscopic surgeon’s guidelines with a co-payment per scope, per procedure (co-payments are the same across all three plans – click here to view them in a pop-up window). Subject to pre-authorisation. |
> Consultations and out-of-hospital procedures – GPs and specialists
|
HEALTHPACT PREMIUM |
HEALTHPACT SILVER |
HEALTHPACT SELECT |
General practitioner consultations and procedures
Any procedure performed by a General Practitioner requires pre-authorisation
|
One GP visit per beneficiary per year, at 100% of CMP tariff - except for PMBs. |
Up to two GP visits per beneficiary per year, at 100% of CMP tariff, thereafter payable from MSA - except for PMBs. |
200% of CMP tariff, payable from MSA, thereafter from day-to-day pool - except for PMBs. |
Registered medical specialist consultations and procedures
Written referral required |
No cover, except for PMBs. Subject to pre-authorisation. |
Payable from MSA - except for PMBs. Subject to pre-authorisation. |
Payable from MSA, thereafter from day-to-day pool - except for PMBs. Subject to pre-authorisation. |
Laparoscopic and endoscopic procedures
Written referral required |
200% of CMP tariff. Laparoscopic procedures as per the endoscopic surgeon’s guidelines with a co-payment per scope, per procedure (co-payments are the same across all three plans – click here to view them in a pop-up window). Subject to pre-authorisation. |
100% of CMP tariff. Laparoscopic procedures as per the endoscopic surgeon’s guidelines with a co-payment per scope, per procedure (co-payments are the same across all three plans – click here to view them in a pop-up window). Subject to pre-authorisation. |
200% of CMP tariff. Laparoscopic procedures as per the endoscopic surgeon’s guidelines with a co-payment per scope, per procedure (co-payments are the same across all three plans – click here to view them in a pop-up window). Subject to pre-authorisation. |
Supplementary services eg. physio, occupational, speech therapists and dieticians
|
No cover, except for PMBs. Subject to pre-authorisation. |
Payable from MSA - except for PMBs. Subject to pre-authorisation. |
Payable from MSA, thereafter from day-to-day pool - except for PMBs. Subject to pre-authorisation. |
> Consultations and out-of-hospital procedures – Dentistry, orthodontics and oral surgery
|
HEALTHPACT PREMIUM |
HEALTHPACT SILVER |
HEALTHPACT SELECT |
General dental practitioner consultations |
No cover |
100% of CMP tariff limited to R553 per beneficiary, thereafter payable from MSA - except for PMBs. Subject to pre-authorisation. |
Payable from MSA, thereafter from day-to-day pool - except for PMBs. Subject to pre-authorisation. |
General dental practitioner procedures In-hospital and according to Dental Protocols |
100% of cost, up to 120% of the CMP tariff for procedures and operations which require hospitalisation, except for PMBs. |
100% of cost, up to 100% of the CMP tariff for procedures and operations which require hospitalisation, except for PMBs. |
100% of cost, up to 120% of the CMP tariff for procedures and operations which require hospitalisation, except for PMBs. |
Orthodontic treatment |
No cover |
Payable from MSA |
Payable from MSA, thereafter from day-to-day pool |
Maxillo-facial surgeons In-hospital procedures
Written referral required |
120% of CMP tariff - except for PMBs. Subject to pre-authorisation. |
100% of CMP tariff - except for PMBs. Subject to pre-authorisation. |
120% of CMP tariff - except for PMBs. Subject to pre-authorisation. |
Maxillo-facial surgeons and orthodontists Dental implants, general dental treatment, orthodontic treatment, orthognathic procedures, periodontic treatment and prosthodontic treatment and according to Dental Protocols |
No cover |
Payable from MSA |
Payable from MSA, thereafter from day-to-day pool |
> Consultations and out-of-hospital procedures – Maternity and paediatrics
|
HEALTHPACT PREMIUM |
HEALTHPACT SILVER |
HEALTHPACT SELECT |
Maternity confinements Birth or delivery
|
200% of CMP tariff; only medically-necessary caesareans are covered - except for PMBs. Subject to pre-authorisation. |
100% of CMP tariff; only medically-necessary caesareans are covered - except for PMBs. Subject to pre-authorisation. |
200% of CMP tariff; with cover for elective caesareans are covered - except for PMBs. Subject to pre-authorisation. |
Ante-natal consultations and foetal scans In- or out-of-hospital
Provided by a registered gynaecological or radiology practice
|
200% of the CMP tariff, limited to R2,396 per family per year - except for PMBs |
100% of the CMP tariff, limited to R2,396 per family per year, thereafter payable from MSA - except for PMBs |
200% of the CMP tariff, limited to R2,996 per family per year, thereafter payable from MSA and then from day-to-day pool - except for PMBs |
Paediatrician consultations
|
200% of CMP tariff, limited to R2,029 per child per year - except for PMBs |
100% of the CMP tariff, limited to R956 per child per year, thereafter payable from MSA - except for PMBs |
200% of the CMP tariff, payable from MSA, thereafter from day-to-day pool - except for PMBs |
Paediatrician procedures and operations |
200% of CMP tariff. Subject to pre-authorisation. |
100% of CMP tariff. Subject to pre-authorisation. |
200% of CMP tariff. Subject to pre-authorisation. |
> Consultations and out-of-hospital procedures – Diagnostics – x-rays, radiology and pathology
|
HEALTHPACT PREMIUM |
HEALTHPACT SILVER |
HEALTHPACT SELECT |
Radiologist procedures, Angiograms, CT scans, duplex doppler scans, interventional radiology, MRI scans, and nuclear medical investigations
Written referral required |
100% of CMP tariff, limited to R12,524 per beneficiary per year, with a co-payment of R1,500 per event on all procedures - except for PMBs. Subject to pre-authorisation. |
100% of CMP tariff, limited to R12,524 per beneficiary per year, with a co-payment of R1,500 per event on all procedures, thereafter payable from MSA - except for PMBs. Subject to pre-authorisation. |
100% of CMP tariff, limited to R12,524 per beneficiary per year, with a co-payment of R1,500 per event on all procedures, thereafter payable from MSA and then from day-to-day pool - except for PMBs. Subject to pre-authorisation. |
Black and white x-rays
In-hospital |
100% of CMP tariff. Subject to pre-authorisation. |
100% of CMP tariff. Subject to pre-authorisation. |
100% of CMP tariff. Subject to pre-authorisation. |
Black and white x-rays Out-of-hospital |
No cover, except for PMBs |
Payable from MSA - except for PMBs |
Payable from MSA, thereafter from day-to-day pool - except for PMBs |
Mammogram benefit
Provided by a registered radiology practice |
100% of the CMP tariff, with co-payment of R300 per female beneficiary over the age of 49 years, once every 2 years, limited to R1,613 – except for PMBs. Subject to pre-authorisation. |
100% of the CMP tariff, with co-payment of R300 per female beneficiary over the age of 49 years, once every 2 years, limited to R1,613 with co-payment of R300 . Thereafter, payable from MSA – except for PMBs. Subject to pre-authorisation. |
100% of the CMP tariff, with co-payment of R300 per female beneficiary over the age of 49 years, once every 2 years, limited to R1,613 with co-payment of R300 . Thereafter, payable from MSA, and then from day-to-day pool – except for PMBs. Subject to pre-authorisation. |
Bone density benefit
Provided by a registered radiology practice |
100% of the CMP tariff, per beneficiary, over the age of 50, once every 5 years - except for PMBs |
100% of the CMP tariff, per beneficiary, over the age of 50, once every 5 years. Thereafter payable from MSA - except for PMBs |
100% of the CMP tariff, per beneficiary, over the age of 50, once every 5 years. Thereafter payable from MSA, and then from day-to-day pool - except for PMBs |
Pathology services in-and-out of hospital
With Pathcare and Lancet Laboratories who are SANAS-accredited
Written referral required |
In-and-out pathology is covered in full as long as you use Pathcare or Lancet Laboratories, who are SANAS-accredited
In-hospital pathology services performed by a service provider other than Pathcare or Lancet Laboratories, will only be covered from your insured benefits during the first 24 hours (of an emergency admission), and only when approved by CMP and performed by a SANAS-accredited pathologist
Any out-of-hospital pathology will be for your own account, if you don’t use a Preferred Provider (Pathcare or Lancet) |
In-and-out pathology is covered in full as long as you use Pathcare or Lancet Laboratories, who are SANAS-accredited
In-hospital pathology services performed by a service provider other than Pathcare or Lancet Laboratories, will only be covered from your insured benefits during the first 24 hours (of an emergency admission), and only when approved by CMP and performed by a SANAS-accredited pathologist
Any out-of-hospital pathology will be paid from available funds in your Medical Savings Account (MSA), if you don’t use a Preferred Provider (Pathcare or Lancet) |
In-and-out pathology is covered in full as long as you use Pathcare or Lancet Laboratories, who are SANAS-accredited
In-hospital pathology services performed by a service provider other than Pathcare or Lancet Laboratories, will only be covered from your insured benefits during the first 24 hours (of an emergency admission), and only when approved by CMP and performed by a SANAS-accredited pathologist
Any out-of-hospital pathology will be paid from available funds in your Medical Savings Account (MSA) or your day-to-day benefits, if you don’t use a Preferred Provider (Pathcare or Lancet) |
> Consultations and out-of-hospital procedures – Prostheses, dialysis, organ transplants and oncology
|
HEALTHPACT PREMIUM |
HEALTHPACT SILVER |
HEALTHPACT SELECT |
Prostheses and implants, excluding hearing devices and dental implants
Refer to Prostheses and Implants price list |
If introduced internally as an integral part of an operation, 100% of cost, subject to CMP’s prosthetic price list. Limited to R45,912 per beneficiary per year. Subject to pre-authorisation. |
If introduced internally as an integral part of an operation, 100% of cost, subject to CMP’s prosthetic price list. Limited to R45,912 per beneficiary per year. Subject to pre-authorisation. |
If introduced internally as an integral part of an operation, 100% of cost, subject to CMP’s prosthetic price list. Limited to R45,912 per beneficiary per year. Subject to pre-authorisation. |
External prostheses and surgical appliances (e.g. wheelchairs, crutches, etc.) |
No cover, except for PMBs. Subject to pre-authorisation. |
100% of cost, payable from MSA - except for PMBs. Subject to pre-authorisation. |
Payable from MSA, thereafter from day-to-day pool - except for PMBs. Subject to pre-authorisation. |
Chronic renal dialysis |
Provided that PMB level of care criteria are met and treatment is provided by a Preferred Provider, covered at 100% of CMP tariff. Subject to pre-authorisation. |
Provided that PMB level of care criteria are met and treatment is provided by a Preferred Provider, covered at 100% of CMP tariff. Subject to pre-authorisation. |
Provided that PMB level of care criteria are met and treatment is provided by a Preferred Provider, covered at 100% of CMP tariff. Subject to pre-authorisation. |
Organ transplants |
Provided that PMB level of care criteria are met and treatment is provided by a Preferred Provider, covered at 100% of CMP tariff. Subject to pre-authorisation. |
Provided that PMB level of care criteria are met and treatment is provided by a Preferred Provider, covered at 100% of CMP tariff. Subject to pre-authorisation. |
Provided that PMB level of care criteria are met and treatment is provided by a Preferred Provider, covered at 100% of CMP tariff. Subject to pre-authorisation. |
Oncology treatment |
Provided the formularies and treatment protocols of CMP and the SA Oncology Consortium (SAOC) tier guidelines are applied in accordance with an agreed treatment plan, covered at 100% of the CMP tariff, as per the SA Oncology Consortium’s Primary Level of Care treatment guidelines. Treatment plan subject to approval and pre-authorisation. |
Provided the formularies and treatment protocols of CMP and the SA Oncology Consortium (SAOC) tier guidelines are applied in accordance with an agreed treatment plan, covered at 100% of the CMP tariff, as per the SA Oncology Consortium’s Primary Level of Care treatment guidelines. Treatment plan subject to approval and pre-authorisation. |
Provided the formularies and treatment protocols of CMP and the SA Oncology Consortium (SAOC) tier guidelines are applied in accordance with an agreed treatment plan, covered at 100% of the CMP tariff, as per the SA Oncology Consortium’s Primary Level of care and Standard Level of Care curative treatment guidelines. Treatment plan subject to approval and pre-authorisation. |
Anti-emetics, vitamins, cosmetic and prosthetic appliances forming part of oncology treatment |
No cover, except for PMBs. Subject to pre-authorisation. |
Payable from MSA - except for PMBs |
Payable from MSA, thereafter from day-to-day pool - except for PMBs |
> Consultations and out-of-hospital procedures – Prescribed medication
|
HEALTHPACT PREMIUM |
HEALTHPACT SILVER |
HEALTHPACT SELECT |
Chronic medication Subject to authorisation |
100% of cost to a maximum of Single Exit Price plus the Preferred Provider dispensing fee. Subject to chronic programme protocols. |
100% of cost to a maximum of Single Exit Price plus the Preferred Provider dispensing fee. Subject to chronic programme protocols. |
100% of cost to a maximum of Single Exit Price plus the Preferred Provider dispensing fee. Subject to chronic programme protocols. |
Acute medication |
No cover, except for PMBs |
100% of cost to a maximum of Single Exit Price, plus the agreed Preferred Provider dispensing fee. Limited to R708 per family; thereafter payable from MSA - except for PMBs |
100% of cost to a maximum of Single Exit Price, plus the agreed Preferred Provider dispensing fee. Payable from MSA, thereafter from day-to-day pool - except for PMBs |
Take-home medication |
No cover, except for PMBs |
Payable from MSA - except for PMBs |
Payable from MSA, thereafter from day-to-day pool - except for PMBs |
> Consultations and out-of-hospital procedures – Spectacles, contact lenses and supplementary services
|
HEALTHPACT PREMIUM |
HEALTHPACT SILVER |
HEALTHPACT SELECT |
Spectacles and contact lenses |
No cover, except for PMB |
100% of cost, payable from MSA - except for PMBs |
100% of cost, payable from MSA, thereafter from day-to-day pool - except for PMBs |
Supplementary services Refer to additional notes and terminologies |
No cover, except for PMBs |
100% of cost, payable from MSA - except for PMBs |
100% of cost, payable from MSA, thereafter from day-to-day pool - except for PMBs |
> Preventative benefits
|
HEALTHPACT PREMIUM |
HEALTHPACT SILVER |
HEALTHPACT SELECT |
Preventative and screening benefits |
Mammograms for females > of 49 – Refer to page 5. Bone mineral density test for beneficiaries > 50 – Refer to page 6. Pap smear on request of a medical doctor – Refer to page 6. Prostate test (PSA level) for males – Refer to page 6. Antenatal visits for pregnant moms – Refer to page 5. Voluntary HIV testing and counselling – Refer to page 6. Flu vaccine for beneficiaries registered for asthma or chronic obstructive pulmonary disease. The only scheme that provides all out-of-hospital pathology requested by a medical doctor, which includes but is not limited to blood glucose, cholesterol, thyroid screening and COVID-19 testing. |
Mammograms for females > of 49 – Refer to page 5. Bone mineral density test for beneficiaries > 50 – Refer to page 6. Pap smear on request of a medical doctor – Refer to page 6. Prostate test (PSA level) for males – Refer to page 6. Antenatal visits for pregnant moms – Refer to page 5. Voluntary HIV testing and counselling – Refer to page 6. Flu vaccine for beneficiaries registered for asthma or chronic obstructive pulmonary disease. The only scheme that provides all out-of-hospital pathology requested by a medical doctor, which includes but is not limited to blood glucose, cholesterol, thyroid screening and COVID-19 testing. |
Mammograms for females > of 49 – Refer to page 5. Bone mineral density test for beneficiaries > 50 – Refer to page 6. Pap smear on request of a medical doctor – Refer to page 6. Prostate test (PSA level) for males – Refer to page 6. Antenatal visits for pregnant moms – Refer to page 5. Voluntary HIV testing and counselling – Refer to page 6. Flu vaccine for beneficiaries registered for asthma or chronic obstructive pulmonary disease. The only scheme that provides all out-of-hospital pathology requested by a medical doctor, which includes but is not limited to blood glucose, cholesterol, thyroid screening and COVID-19 testing. |
> Conditions covered on the chronic medicine benefit
WHICH CONDITIONS ARE COVERED ON THE CHRONIC MEDICATION BENEFIT? |
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. |
|
> What doesn't CMP cover
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
|
|
> Additional notes and terminologies
ADDITIONAL NOTES AND TERMINOLOGIES |
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
To ensure payment of PMB claims, PMB treatment must conform to CMP’s formularies and protocols, and all ICD-10 and PMB codes must be recorded on
a claim. Failure to adhere to these rules may result in payment only in accordance with the prescribed levels, and a co-payment and payment shortfall may
apply (PMBs may not be paid for from the MSA). CMP reserves the right to investigate all PMB claims, and to request and obtain supporting documentation
as we deem necessary.
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).
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Procedure |
Co-payment amount |
Arthroscopy |
R1,000 |
Appendectomy |
R1,000 |
Inguinal hernia repair |
R1,000 |
Gynaecological procedures |
R1,000 |
Urology procedures |
R1,000 |
Umbilical hernia repair |
R1,000 |
Incisional hernia repair |
R1,000 |
Ventral hernia repair |
R1,000 |
Colectomy |
R1,000 |
Colonoscopy |
R1,000 |
Gastroscopy |
R1,000 |
Hysteroscopy |
R1,000 |
Sympathectomy |
R1,000 |
Vaginal hysterectomy |
R1,000 |
Cystoscopy |
R1,000 |
Device |
Maximum amount |
Cardiac stents |
R14,345 per stent |
Trans-vaginal tape |
R9,805 |
Intra-ocular lenses |
R2,880 per lens |
Patches used in incisional hernia repair |
R3,922 |
Patches used in groin hernia repair |
R1,314 |
Joint replacements |
R45,912 |
Pacemakers, including leads |
R45,912 |
Thinking of joining CMP? Get started by submitting a membership enquiry.
Get comprehensive hospital cover for unexpected events.
Find out more
Get affordable hospital cover and savings for day-to-day expenses.
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Be sure that your day-to-day expenses are adequately covered.
Find out more
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