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Medical aid glossary

Please select a letter below:


A -  B -  C -  D -  E -  F -  G -  H -  I -  J -  K -  L -  M -  N -  O -  P -  Q -  R -  S -  T -  U -  V -  W -  X -  Y -  Z

A

Authorisation

In the case of medical emergencies, including emergency road transport services, authorisation will still be compulsory and must be requested within 72 hours of the incident.

Agreed tariff (AT)

CMP has negotiated a fixed tariff with the 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 CMP tariff, is 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.

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B

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.


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.


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.


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.


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C

Co-ordinated care

Co-ordinated care is for planned hospitalisations or procedures that require authorisation and that would normally be paid from the insured benefits of your product. In the interests of better co-ordinated care and the management of costs, members must have a written motivation from their General Practitioner (GP) or family physician before seeing a specialist, should they require any form of hospitalisation or procedure.

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.


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.


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 beneficiaries as well as the plan, is then pooled and used to pay out member claims.

Contracted out

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

Contracted in

If a medical practice is contracted in, it means that their fees are on par with the 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.

Consultation

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


Condition-specific waiting period

As part of the underwriting process, new members may have a condition-specific waiting period imposed. 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.

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 usually offer comprehensive cover.

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.


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 per scope payable on all laparoscopic and endoscopic procedures.  A co-payment is not the same as a payment shortfall.

CMP tariff

As with every medical scheme, CMP has calculated its own medical scheme rate (MSR). The CMP tariff/rate is the maximum amount CMP will pay for products and services.


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.


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.


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.


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.


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 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 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.


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.


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.


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D

Day-to-day pool

At the beginning of each year, HealthPact Select beneficiaries are allocated a versatile pool of benefits to pay for additional day-to-day expenses. This day-to-day pool comes into effect once MSA funds are depleted.  Unlike the MSA, benefits remaining at the end of the year are not carried over to the following year. 

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.


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.


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.


Day-to-day benefits

In addition to in-hospital benefits and an MSA, HealthPact Silver beneficiaries are also allocated some built-in specific and fixed annual day-to-day benefits like two GP visits, separate dental cover and an acute medicine benefit. Unlike the MSA, any of these remaining day-to-day benefits are not carried over to the following year. Benefits are pro-rated if a member joins the Scheme after 1 January of each year. 

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E

Emergency services

These services must also be provided by a registered ambulance service.

In the case of medical emergencies, including emergency road transport services, authorisation is compulsory and must be requested within 72 hours of the incident

If you will be requiring airlifting services, you will need to get pre-authorisation for this.


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.


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.


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F

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.


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.


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G

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.


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.


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 - including emergencies - will be paid.

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H

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.


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.


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I

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.


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.


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.


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L

Late joiner penalty

If a new member is over the age of 35 on joining they might be charged an additional fee depending on their proven (certificate of membership) length of previous, South African medical scheme membership. 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.


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M

Member Transfer Funds

These are funds that are transferred from a member’s previous Medical Savings Account (MSA) into their new MSA when they become a member of CMP.  Only the HealthPactSilver and HealthPact Select plans at CMP have MSAs.

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.


Minor

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


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 (also known as member subscriptions), which vary according to the type of member as well as the plan, are then pooled and used to pay out member claims.

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.


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.

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, 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.

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.


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.


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. 


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N

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.


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.


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O

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.


Option

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

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.


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P

Preventative care

This is the care you receive to prevent illnesses or diseases. Providing these services is based on the idea that getting preventative care, such as screenings via various diagnostics and specific consultations can help you and your family stay healthy.  Examples of preventative care are pathology and radiology benefits, including mammograms and bone density scans as well as GP, specialist and various maternity benefits.

Payment shortfall

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 for from a member's medical savings account (MSA). But if savings are depleted, members become personally liable for the amount.  A payment shortfall is not the same as a co-payment.

Public/State/Government sector

Each provincial government in South Africa funds and maintains a system of publically accessible hospitals.

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.


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.


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.


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.


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.


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.


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-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, 2 - 4 days prior to the event. Members will be required to sign the accepted quote.  In the case of medical emergencies and road transport services, authorisation will still be compulsory, and must be requested within 72 hours of the incident.  Pre-authorisation is compulsory when airlifting services are required (before lift off).  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. 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 and authorisation, please call 021 937 8300 or email mrm@cmp.co.za during office hours. 

Plan

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

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).


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.


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.


Preferred Provider

To help contain costs, CMP has negotiated with selected healthcare partners, also known as Preferred Providers (service providers appointed by CMP to diagnose, treat and care for our members).  Treatment for Prescribed Minimum Benefit (PMB) conditions is provided by any government/state facility in the Western Cape and Gauteng or a CMP-nominated service provider. This doesn’t mean that you will definitely have to go to a state facility. The Scheme must first be given the opportunity to advise about access to a state facility, and if the state facility is unable to take on the case and can prove they can’t, then we will suggest or nominate a private service provider that will charge the CMP tariff/rate. If you choose not to use our Preferred Provider, you will have to pay a portion of the bill as a co-payment and/or payment shortfall. Chronic medication is provided by any Clicks Pharmacy, government state facility, or any other pharmacy, but the CMP dispensing fee is capped at a negotiated rate. Pathology must be performed by South African National Accreditation System (SANAS)-accredited pathologists.

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R

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.


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.


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.


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S

SANAS accreditation

Pathcare and Lancet Laboratories are our Preferred Providers for pathology services and are SANAS accredited.  The South African National Accreditation System (SANAS) is recognised by the South African government as the single National Accreditation Body that gives formal recognition that medical laboratories deliver the required quality of work by meeting accreditation criteria.

Supplementary services

On HealthPact Silver and Select, cover is available for selected additional medical services (subject to available MSA/day-to-day pool respectively). These services will require separate pre-authorisation if required in-hospital, or once you leave hospital, if they are related to the hospital procedure you underwent.  These supplementary services include aromatherapists, chiropodists, chiropractors, dieticians, hearing aid acousticians, homeopaths, herbalists, naturopaths, occupational therapists, orthotists, orthoptists, physiotherapists, podiatrists, psychiatrists, psychologists, physical medicine practitioners, reflexologists, social workers, speech therapists and sexologists.

State/Government/Public hospital

Each provincial government in South Africa funds and maintains a system of publically accessible hospitals.

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.


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.


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.


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.


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U

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.


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W

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).


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