If you’ve been diagnosed with a disease lasting more than three months which is a chronic condition and you then need ongoing treatment. If the medication falls within your medical aid's chronic disease list, you then will be able to use your benefit for chronic medication. Below is a few question answered from the Council of Medical schemes which regulates medical schemes. Is my medical scheme obliged by law to provide cover for certain medical conditions? Yes, these are known as Prescribed Minimum Benefits (PMBs). They were introduced into the Medical Schemes Act to ensure that beneficiaries of medical schemes would not run out of benefits for certain conditions and find themselves forced to go to State hospitals for treatment. These PMBs cover a wide range of ±270 conditions, such as meningitis, various cancers, menopausal management, cardiac treatment and many others, including medical emergencies. However, take note that certain limitations could apply, such as the use of a Designated Service Provider and specified treatment standards. PMB diagnosis, treatment and care are not limited to hospitals. Treatment can be received wherever it is most appropriate, including a clinic, outpatient setting or even at home. Always check your benefits with your medical scheme and make sure you have the scheme's rules at your disposal. Is it true that schemes now also have to provide chronic medication? Yes, the list of PMBs includes 25 common chronic diseases in the Chronic Disease List (CDL) and other chronic conditions within the ±270 Diagnosis Treatment Pair (DTP) section. Medical schemes have to provide cover for the diagnosis, treatment and care of these diseases. However, you should remember that a medical scheme does not have to pay for diagnostic tests that establish that you are not suffering from a PMB condition. The treatment algorithms (guidelines for appropriate treatment) for each of the CDL chronic conditions have been published in the Government Gazette while the chronic diseases in the DTP section are guided by the public sector protocols. This assures you of good quality treatment and reassures your medical scheme that it will not have to pay for unnecessary treatment. Your doctor should know and understand most of the guidelines so that he or she can help you get the treatment you need for any of these conditions without incurring costs that your scheme does not cover. Why are some chronic illnesses covered and some not? The diseases that have been chosen are the most common, they are life-threatening, and are those for which cost-effective treatment would sustain and improve the quality of the member's life. Does my scheme need to do anything to ensure that the Designated Service Provider can treat me? The Council for Medical Schemes has been advising medical schemes to enter into contracts with any DSP they choose, especially State hospitals, to ensure that these providers can supply the necessary services. Many State hospitals have set up separate wards to serve beneficiaries whose treatment and hospital stay is paid for by their medical scheme and to whom the hospital can then afford to provide better service. Other schemes have made arrangements with private hospital and certain retail pharmacies to treat their beneficiaries. Can I be refused cover for the chronic conditions if I do not get authorisation or have certain tests? Yes, medical schemes can make a benefit conditional on you obtaining pre-authorisation or joining a benefit management programme. These programmes are aimed at educating members about the nature of their disease and equipping them to manage it in a way that keeps them as healthy as possible. For example, many schemes offer treatment through groups that manage diseases such as diabetes, and are equipped to give the medication and monitor that disease. To register for your Chronic medication please contact Namhla in our Health Department email [email protected] , tel (011)658 -1333 Source: Council for Medical Schemes
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What is it? A Medical Scheme Fees Tax Credit (also known as an “MTC”) is a rebate which reduces the normal tax a person pays. This rebate is non-refundable and any portion that is not allowed in the current year can’t be carried over to the next year of assessment. It applies for years of assessment starting on or after 1 March 2012 (from the 2013 year of assessment). Who is it for? The MTC effectively replaced part of the tax deduction that was specifically allowed for medical scheme contributions, and applies to fees paid by a taxpayer to a registered medical scheme (or similar registered scheme outside South Africa) for that taxpayer and his or her "dependants" (as defined in the Medical Schemes Act). This MTC seeks to bring about greater fairness and help achieve greater equality in the treatment of medical expenses across all income groups. The MTC is a fixed monthly amount which increases according to the number of dependants: How does it work?
The MTC will effectively impact both the employer and the employee. This credit must be taken into account by the employer when calculating the amount of Employees’ Tax to be deducted from the employees’ remuneration. Individuals who have not had their MTC taken into account by an employer (for example, an individual who is retired and receives a pension; or an individual who is self-employed) can claim the MTC on assessment by submission of an annual income tax return. If you need assistance with getting your medical aid tax certificate please contact Namhla in our Health department, email [email protected] , tel (011)658-1333 Source: Sars People often believe that if you gather significant assets during your lifetime and put enough into your retirement or pension fund during your career, you don't have to worry about living comfortably in your later years. But in an environment where medical costs are rising and markets are constantly fluctuating, is that really true? Here's a figure that might be surprising if you are planning to retire soon and haven't considered your health care costs. If you are 65 and retiring this year, you will need about R990 000 during retirement to keep up the same cover you currently enjoy. For a couple, that total is about R1 990 000. (assuming you are on the Discovery Health Medical Scheme, on the Classic Delta Comprehensive Plan, a contribution of R4059 to your plan, and that your retirement grows in line with medical inflation- currently CPI +4%). These numbers are based on the assumption that a man will live to be 85 and a woman 87, however with publications like the scientific research journal Nature reporting that children born in 2000 will live to be 100 years or older we may need even more retirement and medical savings in the future. With our longer life spans, financial planning for retirement has never been more important if we want to maintain your lifestyle over the long term. So how much is enough? It’s easy to miscalculate how much you’ll need in retirement. Underestimate what you will need and retire too soon and you could run out of money in your retirement years. Overestimate and you might keep working longer than is necessary or deprive yourself of trips, restaurant meals and other luxuries unnecessarily. Bottom Line Personal asked retirement-planning professor, Michael Finke, what he sees as the top 3 most common mistakes made by people when planning for retirement. Number one, he says is that people often overestimate the amount medical aid and insurance will cover, number two, that they underestimate health-care inflation and the third mistake that they do not consider or factor in the possibility that they could need long-term care in retirement. On how to more accurately estimate medical expenses in retirement Finke suggested that you start with what you currently spend on health care annually, or if that figure has fluctuated greatly, take the average you have spent over the past five years. Then also factor in that the Consumer Price Inflation (CPI) in South Africa has increased by 6.3% a year on average since 2008, and medical scheme contributions are increasing by at least CPI 3-5% annually. What can we do to plan better for the future? It is important to engage in a healthy lifestyle. 60% of diseases afflicting people worldwide are lifestyle diseases. To help aid in a happy, active retirement, protect your health by embarking on regular exercise, a balanced diet and maintaining a weight that is correct for your body type. The healthier you keep your body; the better the chances are that you would not need to spend as much money on healthcare bills as you age. Of course, there are will always be unforeseen illnesses which will catch you off guard but it is important to make provisions where you can, so that medical bills will be one less thing that you would need to worry about as you enter into retirement. Invest in yourself and pick the right plan Government care may be sufficient for many pensioners; however, many may require immediate or specialised levels of care that are not readily available at state facilities. Some medical schemes may also impose substantial late joiner penalties, waiting periods and exclusion if a pensioner joins for the first time. Having adequate retirement funds to cover medical cost will ensure you get the care and treatment you need when you need it. Covering your medical expenses in retirement requires planning and Discovery Invest has created funds that help you fund your healthcare expenses in retirement. They also give you up to 15% more money for your retirement savings. To get us to review so as to ensure sufficient retirement savings, please contact Kevin or Thato, email: [email protected] tel no: (011 658-1333) Source: Finance24 Imagine finding out that your pharmacist or doctor has been arrested for submitting an account for care that was not administered, or for over-billing for supplies and services. Imagine finding out that he or she falsified patient data to obtain a higher payments from medical schemes, or had been paid kickbacks to refer patients to a specific specialist or clinic. These are some examples of medical scheme fraud, which exacts a human and financial toll on our nation. The loss of funds not only compromises the financial integrity of medical schemes, but also undermines their ability to provide healthcare services to the more than nine million people who depend on schemes. Medical fraud has directly affected the quality of health care and put some of the most vulnerable patients at risk. Many patients are harmed as a result of unnecessary procedure. Medical schemes and their administrators are having to spend substantial sums of money on analytical software capable of detecting irregular claims. Fraud and abuse are rife. It is estimated that at least 10% to 15% of all claims are fraudulent, abusive or wasteful in nature. In a R150-billion industry, that is a substantial expense. Fraud and waste are defined as intentional deception or misrepresentation, misreporting data to increase payments, paying kickbacks to providers for referring patients for services or to entities, or stealing providers’ or patients’ identities. Examples of fraud are billing for non-rendered services or supplies, misrepresenting diagnoses to obtain payments and accepting kickbacks. Abuse includes practices of providers, physicians or suppliers of services that are inconsistent with accepted medical practice, or that are not reasonable and necessary, resulting in unnecessary costs to medical schemes. One of the most common types of abuse involves the miscoding of claims. Every year, medical schemes are cheated out of billions of rands, which results in higher contributions and co-payments for members. Healthcare fraud and abuse are hard to contain because of a variety of factors, including the volume of claims associated with a single healthcare event and the emotive nature of “the story” linked to every claim. Payment by the medical scheme has become an expectation, a right that cannot be denied. Solutions for stopping medical fraud include: making better use of technology; higher penalties; improved provider enrolment procedures; greater rewards for reporting fraud; educating beneficiaries; and empowering patients and providers so they can identify and report fraud. Here are some important steps that members of medical schemes can take to ensure that they do not become victims of medical fraud.
Source: Personal Finance What is Gap cover? GAP cover pays YOU the difference between what the doctors charge in hospital and NHRPL, what the medical aid actually pays. The National Health Reference Price List (NHRPL) is a pricing system maintained by the Department of Health and the Council for Medical Schemes. The NHRPL specifies the rates to which your medical aid scheme must adhere. It is the amount of money that they are bound by law to pay out for a given situation. Doctors, hospitals and other medical service providers however, are not bound to these rates, and in fact charge up to 300% above these NHRPL prices. So despite thinking you are financially covered for any medical eventuality in its entirety, for the most part you are not, and are often liable for an enormous shortfall. Gap Cover policies are proving to be an invaluable safety net, as the shortfall between what medical schemes pay and what specialist doctors charge has widened, leaving policy holders with a medical bill big enough to put them back in hospital. To ensure you don’t find yourself with unpaid medical bills contact Namhla in our Health, email [email protected] , tel (011)658-1333 and apply for gap cover Source: Covergap With this year’s National Budget, as announced by Minister Pravin Gordhan on Wednesday 22 February 2017, the following fast facts as it relates to the healthcare industry are highlighted for your attention
Source: Resomed It’s tempting to want to splurge on over-the-counter vitamins and supplements or some other lifestyle item when medical aid benefits, limits and savings accounts get renewed come 1 January each year, especially after the costly festive season spending. GTC’s Head of Healthcare Consulting, Jill Larkan, cautions however that members should spend medical aid savings prudently and use benefits wisely, particularly in the early part of the New Year. “The governing body of this sector - the Council for Medical Schemes (CMS) - recently released commentary urging members to make medical aid benefits last longer,” says Larkan. “We completely concur with the CMS. Spending sensibly from the outset helps to extend the availability of funds later in the year, while ensuring you are able to retain a positive balance in your savings account for as long as possible.” The acting Chief Executive and Registrar at the CMS, Mr Daniel Lehutjo, said in his statement that “members should resist the urge to spend all their benefits in the first couple of months” and “not to use your benefits to buy sunglasses, multivitamins or other lifestyle items over the counter.” All South African medical aids run financial years concurrent with the calendar year. This means that all the benefits (with the exception of oncology), limits and savings accounts are “renewed” on 1 January each year. When the New Year comes around a bulk lump sum of money is allocated to every member’s medical aid savings accounts and this sum is the accumulation of the next twelve, savings allocation portions, of the monthly premiums. “The lump sum of advanced annual savings needs to last until the end of December, and any non-essential items purchased now may unnecessarily increase any self-payment gaps which may require attention later in the year, once your savings are exhausted,” continues Larkan. Some additional tips from Larkan and the CMS which would help to extend members’ medical aid savings include: • Check if your medical aid has a formulary list of medications and if they do have one, request that your doctor, as far as possible, only dispenses listed medicines. A formulary is a list of prescribed medications – both generic and branded, for which your medical aid scheme will pay. The formulary helps to guide you to the most cost-effective medications that are effective for treating a particular condition. • If your scheme offers preventative screening tests, paid for by the scheme, get a list of these, and have as many done as possible, ensuring that any potential health issues are detected and addressed as early as possible. • If you take chronic medication, check that you are registered as a chronic medication member with your scheme, ensuring that as much of your monthly costs as possible are covered, by your scheme. If there is a Chronic Management program for your ailment, register for this and follow the program to improve, monitor and maintain your health. • Ensure that you know whether there is a designated service provider stipulated by your medical aid which you are required to use for various medical procedures. These service providers may include pharmacies, hospitals, doctors, specialists and even optometrist networks. Ensuring the designated service providers are used will help to curb additional expenses which service providers not in the network/s may be charging. • Obtain procedure codes and confirm authorisation and cover levels provided by your scheme. Understand what your portion of payment will be. Discuss these rates/tariffs with your doctor and negotiate these wherever possible. “By incorporating as many of these strategies as possible, members will be well on their way to maximising valuable medical aid savings. Professional advice from experienced medical aid consultants and advisors should be sought – whether through one’s employer or in a personal capacity – to ensure the retention of as much of your savings as possible,” Larkan concludes. To find out more on what your savings are from our different medical scheme providers please contact Namhla or Judy in our Health and Wellness Department, email [email protected], tel (011)658-1333 Source: FANews |
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January 2025
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