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What is a co– payment?
It is a portion of the cost for which you are responsible.
Is membership of a medical scheme available to any person?
Yes, except in a restricted membership scheme, for instance where a particular employer, profession, trade, industry, calling association or union has established a scheme exclusively for its employees or members.
Can I belong to more than one medical scheme at the same time?
No it is illegal.
May a medical scheme refuse to admit my dependant?
No, in terms of the Medical Schemes Act no medical scheme may refuse to admit a person who are dependent on the member. Dependants of a member are his/ her spouse or partner, child under the age of 21 or older and a child who is dependent upon the member due to a mental of physical disability; immediate family in respect of whom the member is legally liable for family care and support and such other persons who are recognized by the scheme as dependents. Immediate family is classified as the mother, father, brother, or sister of the member. The scheme concerned may require proof of such dependency and appropriate additional contributions in respect of such extended cover must be expected.
If a member dies, will his registered dependants still be covered?
Yes without any break in membership and provided contributions are paid. It is important to inform the scheme if one chooses not to continue.
Must I give notice to the scheme in the event that I wish to terminate membership?
Yes the notice period stipulated in the rules must be complied with.
Am I entitled to benefits while serving notice of termination?
Yes, until the last day of membership provided contributions are being paid.
May a medical scheme determine contributions on the basis of individual high claims or provide for discounted or preferred rates in respect of a particular group of members/Clients for whatever reason?
No, contributions may only be based on a members income and/or the number of his dependants or both. The contributions apply universally to all members who are enrolled an their dependents.
What can I do if I am not satisfied with my current benefit option?
Instead of changing schemes and be faced with waiting periods, a member can either buy up in order to get better benefits or buy down for less contributions.
To what extent are the prescribed minimum benefits restricted?
No restriction , co-payments, waiting periods or exclusions may be applied to any person in respect of the prescribed minimum benefits if the services are render by State Hospitals or designated service provider (DSP) In instance where services are voluntary obtained from a non—DSP, co payments may apply or waiting periods may be imposed only on those applicants who have never belonged to a medical scheme or have not been beneficiary for the preceding 90 days.
What are the types of waiting periods?
There are two kinds of waiting periods:

i.e General waiting period of up to three months, Condition-specific waiting period of up to 12 months.

Within what period of time must my account for services of claim reach my medical schemes?

The account must be submitted not later than the last day of the fourth month following the month in which the service was rendered.

How do I know whether or not my scheme has paid and what amount has been paid in respect of a claim?

Payment of claims is regulated by the Act, which includes the dispatch to a member of a statement containing full particulars of the transaction, including the amount charged for every service and the amount of the benefit awarded for each service.

Within what period of time must the scheme pay my claim?

If the account or claim is correct and acceptable for payment, it should be paid within 30 days of receipts of the claim.

What is an ex-gratia payment and do I have a right to such benefits?

It is a discretionary benefit which a medical scheme may consider, normally when the member suffers undue hardship. Schemes are not obliged to make provision therefore in the rules and members have no statutory right thereto.

Is a provider of health care service entitled to charge more that the fees determined by medical schemes/ the tariff specified in the NHRPL?
May I participate in the operation of my scheme?
When does a government employee qualify for subsidy?
When am I allowed to change from option?

Only once a year, preferably in the beginning, and a motivation should be attached.

What is a late joiner penalty?

A penalty which may be imposed on a new member joining the scheme, if the member is over the age of 35 and cannot provide proof of sufficient previous membership to a medical scheme.

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