FAQ

FAQ

Can complaints be lodged with the BHF against a healthcare service provider?

It should be noted that the BHF is not a regulatory authority and will not assume the responsibility to regulate the professional conduct of any health professional. By virtue of a PCNS number only being issued to a person who is duly registered with a statutory body, any dispute regarding the legitimacy of either the registration or access to a PCNS number would be deferred to the relevant statutory organisation for a ruling. Where a professional body assumes the responsibility of regulating its membership, the BHF would defer to that organisation to assist in the resolution of any dispute.

Where can I obtain a list of medical schemes?

A list of medical schemes, associations, administrators and councils is available on our website, or a complete list of medical schemes is obtainable from our Client Services Division. You may also contact the Council for Medical Schemes on 012-431-0500 for further enquiries.

Why must I pay BHF for this practice number?

It has been recognised by the PCNS Advisory Forum that the system should be jointly funded on an equitable not-for-profit basis, by healthcare service providers and medical schemes, since these are the two parties who enjoy the benefits of the system. A nominal annual subscription to PCNS allows healthcare service providers who are registered with the relevant authority the use of a unique practice number, which guarantees up to date information to medical schemes and administrators, thereby facilitating more prompt billing and reimbursement. Annual PCNS subscription also entitles providers to the following services:

  • Access to support services from the Client Services Division;
  • Problem resolution pertaining to Recommended Scale of Benefit (RSOB) code description and application thereof for reimbursement;
  • Guidance and appropriate referral on the use of new Recommended Scale of Benefit codes and descriptions; and
  • Verification of your practice details for billing purposes.

Where can I obtain particulars of a specific service provider?

The BHF website allows you to search for the details of a healthcare service provider in your area. You may also contact Med-Pages on TOLLFREE 011 803 6336.

Where can I obtain particulars of a specific medical scheme?

The BHF website allows you to search for the details of a specific medical scheme. You may also contact the Council for Medical Schemes on 012-431-0500 for further enquiries.

The BHF membership consists of more than 95% of all medical schemes in South Africa, Namibia, Zimbabwe and Botswana. This is in keeping with BHF’s regional focus and in sequence with common market developments in the South African Developing Community (SADC).

Where can I obtain a list of Nappi codes

Contact MediKredit at (011) 770 6000.

Medical Schemes Q&A: j. How to choose a Medical Aid Scheme

Decide on your budget, assess your family’s needs and the cover required. Some schemes have high premiums, and more benefits. Others have lower premiums with low day-to-day cover, but good hospital cover. Often, the most affordable benefit options are those which oblige members to access network providers or which oblige members to follow a referral process when accessing specialists. These network options, where you use a specific service provider, often allow you to make use of that network GP and dentist as often as you need. When considering a network option find out whether there are the relevant specialists in your area; whether the other benefits on the scheme suit your needs; and, the extent to which there may be co-payments.

Most medical schemes offer a number of benefit options ranging from fully comprehensive to mostly hospital benefits. Depending on your state of health, you may need more comprehensive medical cover rather than a hospital plan and need to ensure that your option covers your particular condition, including the medication. However, if you are generally healthy and don’t visit the doctor very often then consider a lower cost scheme or hospital plan.

It is cost effective to be on the same medical scheme as your spouse and children. It is often better to stay within an employer’s scheme because these restricted/employer-based schemes often charge according to your income but offer the same benefit to everyone., whereas open schemes often charge a set fee for a certain option irrespective of your income. Certain entry level schemes have a salary ceiling and require proof of income.

Ascertain the rates at which your preferred option pays. The rate at which a scheme pays often differs between options. Check hospital limits. You also need to know whether an option includes a medical savings account.

What is the difference between Medical Aid and Medical Insurance?

Medical aids are clearly the best vehicle for funding health conditions because the benefits you receive are directly related to the cost of the condition which you may suffer from and because they are based on social solidarity principles; ie: all members within the scheme contribute equally into a pool of funds, whether they are young and healthy or chronically ill, and benefits are paid out to those who need them. Effectively, this means that young and healthy people cross subsidize elderly and sick people.

Health insurers are able to play by a different set of rules that come in at a lower cost but they don’t offer the social protection that medical schemes do.

What is PCNS and who qualifies for a practice number?

In accordance with the Medical Schemes Act 131 of 1998, a medical scheme may only reimburse a member or a healthcare service provider directly for services rendered by a provider of service duly registered or licensed with the relevant government department or statutory council. In order to facilitate efficient commerce, a central repository of healthcare provider registration information has been developed over time by the medical scheme industry in the form of a Practice Code Numbering System (PCNS).

To obtain a practice number, it is required that the healthcare service provider be registered as an independent practitioner with the relevant statutory council, and that the healthcare service provider’s scope of practice be recognised by the BHF. In addition to this, there is an application form to be completed (available on this website, or obtainable from our Client Services Division). This application form should be returned to our office by registered mail or overnight courier, together with your registration fee. Your registration should be renewed by the 31st of January of every new year.

It takes up to 10 working days for a practice number to be issued, provided that all the documentation we request accompanies your application form. Once this practice number has been issued, all medical schemes on the PCNS database are notified electronically.

What is BHF and who are its members?

The Board of Healthcare Funders (BHF) was launched in December 1999, to which medical schemes may voluntarily belong. The vision of BHF is “a private healthcare funding system that ensures lifetime access to comprehensive and affordable healthcare for the average working person”.

The Board of Healthcare Funders is a non-for-profit association of schemes of Southern Africa.
The BHF membership consists of more than 95% of all medical schemes in South Africa, Namibia, Zimbabwe and Botswana. This is in keeping with BHF’s regional focus and in sequence with common market developments in the South African Developing Community (SADC).

PCNS Numbers: Are healthcare providers permitted to practice in South Africa without a practice number from PCNS?

The practice number, allocated to all registered healthcare providers is the essential billing code that triggers the process of reimbursement of a claim to either a medical scheme member or service provider. This is in accordance with the requirement of the Medical Schemes Act 131 of 1998 wherein it is stated that a medical scheme may only reimburse a member or a provider of relevant healthcare services for services rendered against a valid practice code number.

Medical Schemes Q&A: m. What is a Medical Savings Account?

Medical Savings Accounts are used for day to day benefits, such as visits to the GP, medication etc. It is important to consider ways of stretching the funds within the medical savings account as much as possible to ensure that they last the entire year. The main thing to remember is that the funds in the savings account belong to you, the member. The wiser you are with those funds, the longer they will last.

Tips on how to make your savings last longer:
• Stick to your medical scheme’s list of medicines, called a ‘formulary’, or use generic medication where possible. That way, co-pays, if any, will be kept to a minimum.
• Verify the medical practitioner’s rate when you make an appointment and ask whether or not you’ll be liable for co-pays.
• Access a primary care provider, such as a GP first. If he/she cannot deal with the ailment, they will refer you to a specialist. Consultation fees for primary care providers are generally lower than those of specialists, and often they will be able to sort out the problem.
• Shop around for your pharmacy. Although there is a set price on all medicines, the professional fees can vary between pharmacies. Chain store pharmacies and supermarkets can supply over-the-counter medicines such as headache tablets and painkillers, at a lower cost because they buy in bulk.
• Don’t pay for over-the-counter medication or vitamins with your medical savings account. Pharmacies sometimes offer discounts for direct payment. Keep medical savings for other services.
• Wellness checks. Pharmacies sometimes offer free wellness checks, for e.g. blood pressure, cholesterol levels, blood sugar etc..
• Clinic sisters can also give injections or do simple tests.
• See what is available for free. Contraceptives and immunisation is free at government clinics.
• Self medicate where appropriate. For minor illnesses such as a cold, or a bug that is doing the rounds, your pharmacist can recommend over-the counter medication. If it is serious, don’t ignore it – go straight to your healthcare provider.
• Keep your medical scheme in the loop. If you have depleted your medical savings account, keep sending receipts of medical bills to your scheme. In some instances you need to go through the self payment gap, and then cover will kick in again.

Medical Schemes Q&A: l. What are Waiting Periods?

As medical schemes are governed under social solidarity principles, it would not be fair to those members who had been contributing to the scheme for a number of years, to fund someone who only joined the scheme when they were suffering from a certain condition or only when they were elderly and needed cover. An analogy could be made of someone without car insurance who has an accident and then insures the car, expecting to be paid out for the accident. If everyone joined a medical scheme only when they needed cover, or when they were likely to need cover, medical scheme premiums would be prohibitively expensive.
Schemes may, by law, apply general and pre-existing condition waiting periods, depending on whether you have previously been a member of a medical scheme.

• When joining a medical scheme for the first time, a general waiting period of three months and a condition specific period of 12 months may apply.
• If you join a new scheme within 90 days of leaving another, then only a general waiting period of 3 months, excluding Prescribed Minimum Benefits may apply.
• When an individual involuntarily transfers to another scheme due to a change of employment or suchlike, waiting periods do not apply; unless the waiting period on the previous scheme has not yet expired.
• When an employer changes the medical scheme of his employees, waiting periods do not apply to staff who had been members of the previous scheme for more than ninety days.
• Most schemes allow option changes at the end of December. Waiting periods don’t apply unless the member is still on the general waiting period.
• Waiting periods do not apply to any dependent born on to the scheme: ie, a woman who is already pregnant when she joins the scheme will not be covered for any maternity costs, however her baby will be ‘born on to the scheme’ and his/her medical costs will be covered from birth.

Medical Schemes Q&A: k. How to make your Medical Scheme Rands go further

Medical scheme contributions generally increase above the rate of inflation. With rising costs on so many fronts, here are some ways to cut your medical expenses.

• Network options can be cost effective: Your choice of provider and facility is limited to those within the network, but often these options cover just as much as the higher-cost options.
• Find out exactly what your medical scheme will cover when an intervention is needed: Obviously this can’t be done if it is an emergency but you can shop around, and you may be able to negotiate with your doctor, specialist, anaesthetist or dentist.
• Self insure: You can choose a less expensive plan where you have to pay for certain procedures. This reduces monthly contributions, but you need to ensure you have money to cover these procedures should you need them.
• Prevention is better than cure: Those in vulnerable population groups for certain illnesses should practice preventative medicine where possible, for example; the flu jab in the case of the elderly or health compromised.
• Disease management programmes: These are offered by some medical schemes for certain diseases; for example, Diabetes. If you have a disease covered by one of these programmes, it is a good idea to register on the programme.
• Buy within your limits: If your medical aid sets a limit for spectacles,, buy within the price range of your limits.

Medical Schemes Q&A: i. What are Prescribed Minimum Benefits?

Prescribed Minimum Benefits (PMB’s), are a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option selected.
PMBs are a feature of the Medical Schemes Act, in terms of which medical schemes have to cover the costs related to the diagnosis, treatment and care of:

  •  emergency medical conditions;
  • a limited set of 270 medical conditions (defined in the Diagnosis Treatment Pairs);
  •  25 chronic conditions (defined in the Chronic Disease List).

When deciding whether a condition is a PMB, the doctor should only look at the symptoms and not at any other factors, such as how the injury or condition was contracted. This approach is called diagnosis-based. Once the diagnosis has been made, the appropriate treatment and care is decided upon as well as where the patient should receive the treatment (at a hospital, as an outpatient or at a doctor’s rooms).
To view the Prescribed Minimum Benefits go to http://www.medicalschemes.com/medical_schemes_pmb/index.htm

Medical Schemes Q&A: h. How a Medical Scheme works

Step One: Money is collected from the members through medical scheme premiums. In line with social solidarity principles under which all schemes are governed, all members are charged the same regardless of the risk they bring to the scheme. This ensures cross subsidization between young and healthy, and elderly and sick.
Medical schemes operate as ‘stokvels’ or collectives where money is paid into a pool and paid out according to need.
Step Two: Claims are paid out on: hospitals, specialists, medicines; general practitioners; dental; optical; ex-gratia payments; supplementary and allied health practitioners; prostheses; appliances; scans; administration costs; managed care costs; etc.
Step Three: Medical scheme legislation dictates that schemes must have at least a 25% reserve level at all times, for the protection of members. Medical schemes are not permitted to make a profit. Therefore, any operating surplus is put into reserves. In recent years however, the claims which have been paid out by schemes have outweighed what the schemes have collected in contributions which has forced schemes to dip into their reserves to pay out the claims.
Medical schemes are governed under social solidarity principles. This means that all members within the scheme contribute equally into a pool of funds, whether they are young and healthy or elderly and sick. Benefits are paid out to those who need them. Effectively, this means that young and healthy people cross subsidize elderly and sick people. Schemes are run like ‘co-operatives’ or ‘stokvels’.

Chronic Conditions: PRESCRIBED MINIMUM BENEFITS

Prescribed Minimum Benefits (PMB’s), are a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option selected.

PMBs are a feature of the Medical Schemes Act, in terms of which medical schemes have to cover the costs related to the diagnosis, treatment and care of:

  • emergency medical conditions
  • a limited set of 270 medical conditions (defined in the Diagnosis Treatment Pairs)
  • 25 chronic conditions (defined in the Chronic Disease List)

When deciding whether a condition is a PMB, the doctor should only look at the symptoms and not at any other factors, such as how the injury or condition was contracted. This approach is called diagnosis-based. Once the diagnosis has been made, the appropriate treatment and care is decided upon as well as where the patient should receive the treatment (at a hospital, as an outpatient or at a doctor’s rooms).

Click here to view the Prescribed Minimum Benefits as described in Annexure A of the Regulations to the Medical Schemes Act.

Consumer Month: Generic Medication

Consumers are often concerned that the low cost of generic drugs means that quality and effectiveness have been compromised to make the cheaper product. On the contrary, generic drugs must be registered by the South African Medicines Controls Council (MCC) who inspect the manufacturing and packaging facilities for compliance with international standards of good manufacturing practice (GMP). The MCC also evaluates the safety, quality and efficacy of the product.

Generic drugs contain the same active ingredient as the original formulation and are the same as the originator (brand-name) product in terms of dosage, intended use, safety, efficacy, strength, route of administration, quality and performance. The generic drug and brand-name drug are therefore interchangeable as they have the same clinical effect after administration.

The MCC requires that generic drugs work as quickly and efficiently as the original brand-name products. Regulatory authorities worldwide accept that if a generic drug is shown to be the same as the brand-name drug, they are deemed to be interchangeable. Therefore, there is no need to redo the drug testing that was done during the development of the brand-name drug. Once the generic drug has been approved and registered by the MCC, the generic company can distribute their product.

The costs of developing a new drug are often very high, therefore the brand-name drug companies register drug patents to protect their intellectual property and research and development costs by preventing any other company from manufacturing or selling a similar medicine. A generic version of the same medicine may be launched to the market as soon as the patent protection of the brand-name ends. There is usually no way to renew a patent once it has expired.

The reason that the selling price of a brand-name medicine is generally higher than that of generic medicines is that the manufacturer needs to recoup the costs of developing the product within the lifetime of the patent. Regulatory authorities worldwide accept that if a generic drug is shown to be the same as the original branded drug, it is interchangeable with the originator and, therefore there is no need to redo the drug testing.

Trademark law requires that generic drugs look different to branded drugs, so generics may be a different colour, shape, taste or contain different inactive ingredients. Adverse reactions to generic drugs are rare. If people experience problems when changing from branded to generics or vice-versa, it is usually a reaction to the variation in the inactive ingredients, as only the active ingredient needs to be the same. Generic drug names use standardised affixes that separate the drugs between and within classes and suggest the name of the drug. Branded drug names are usually capitalised while generic names are not.

The manufacturers of branded name drugs pay for the entire cost of research, development and testing. The manufacturers of generic drugs do not incur the cost of research and development and only have the cost of reverse engineering to develop bioequivalent versions of existing drugs. They can thus maintain profitability at a lower cost to consumers. Competition between brand-name and generic brand manufacturers can lead to substantially lower prices. This competition prevents any single company from dictating the market price of the drug. Generic drug companies also benefit in the marketing efforts of the brand-name company. Many drugs introduced by generic manufacturers have already been on the market for over a decade and are already well known to providers and patients under their brand name.

How can a medical scheme become a BHF member?

Written communication in this regard should be forwarded to the BHF Communications Manager, or fill in the online application form.

Medical Schemes Q&A: a. What is the difference between Gap Cover and a Hospital Cash Plan?

Gap Cover also know as Top-up Cover is offered by short-term insurance companies, and offers the member protection between the amount charged by the medical supplier and the amount paid by the medical scheme. Gap Cover does not guarantee that all co-pays will be covered. They may exclude certain conditions and may apply risk rating principles.

A Hospital Cash Plan pays out a pre-determined amount per day that the member is in hospital and is not generally related to the actual hospital expenses. The cover sometimes starts with effect from the second or third day in hospital and is generally not condition specific, ie: the amount paid is not linked to the patient’s condition.

Medical Schemes Q&A: b. Is it worth having Gap Cover?

Whilst we believe that medical schemes are the correct vehicle for funding healthcare, in the current environment where there are no regulated tariffs which a doctor or hospital must charge, the member is often left with a co-payment. However, we must not be under the misconception that having gap-cover will mean that all co-pays will be covered. Gap-cover companies are short-term insurance companies and are therefore governed under very different principles to medical schemes in that they may apply risk rating principles and may exclude certain conditions.

Medical Schemes Q&A: c. Medical Scheme vs Hospital Plan

Hospital plans are more affordable than a Medical Scheme, but you need to be able to cover day-to-day procedures such as doctor and dentist visits out of your own pocket. If you suffer from chronic medical conditions such as diabetes or arthritis, you may need full medical cover rather than a hospital plan . However, if you don’t visit the doctor very often and have no dependents then consider a hospital plan.

Having a medical aid covers you in full for most high-cost/catastrophic incidents and has varying levels of cover for other conditions, depending on the benefit option selected. South Africa’s private sector doctors and hospitals are world-class and by having a medical aid, you have access to these.

Medical Schemes Q&A: d. What happens if you are in hospital and your funds run out?

The ‘Prescribed Minimum Benefits’ are a set of about 272 hospital-based conditions, 25 chronic conditions and all emergency medical conditions, which every option on every medical scheme must cover. The purpose of this PMB legislation is to protect members of medical schemes from being ‘dumped’ onto the state when their medical scheme cover runs out.

Medical Schemes Q&A: e. What is a Co-Payment?

This is the difference between the amount charged by the medical supplier and the amount paid by the medical scheme. The member is generally responsible for payment of this amount.

Medical Schemes Q&A: g. What is the difference between a Medical Aid and Medical Insurance?

Medical Aids are the best vehicle for funding health conditions because the benefits you receive are directly related to the cost of the condition which you may suffer. The Prescribed Minimum Benefits are covered by Medical Aids.
Medical Insurance is provided by short-term insurance companies and as such are governed by the Financial Services Board.

Medical Schemes Q&A: f. What is Split-Billing?

This is when a medical supplier provides two accounts for the same service. One is sent to the medical scheme, listing the medical scheme tariff amount; and a separate one to the member/patient. In other words, the member will have paid what they thought was a co-payment to the medical supplier, but the amount paid does not appear on the claim sent to the medical aid by the supplier. This is illegal.

CONSUMER ENQUIRY