Medical schemes can be confusing at times, your fund manager answers the common questions asked by you (the member) to help you to optimise your medical scheme benefits.
You can contact the customer care line on (041) 395 4474 where you can access all the relevant departments by selecting the appropriate number – the Hospital Utilisation Management department, Pharmacy Benefit Management department as well as a customer care consultant can be reached by dialing this number.
MEDIMED is proven to be the best value for money compared to similar Schemes and we always strive to show our members that we care.
There are 4 options on MEDIMED: Alpha, Medisave Max, Medisave Standard and Medisave Essential.
- Alpha – this is the most cost effective option on MEDIMED as the contributions are very low.
- Medisave Standard – this is a savings plan and the benefits are income category based.
- Medisave Max – this is structured in the same way as the Standard option concept, except that it has a higher chronic medication benefit and higher savings.
- Medisave Essential – this is a capitated option. This option is unfortunately only available to members in the Nelson Mandela Metropole as this is the area where we have specific contracts with the providers.
The Alpha option is the most popular and is, in essence, a “pay-upfront” option. We therefore, recommend that members:
- Negotiate cash discounts with providers.
- To relieve the pain of having to pay upfront with cash:
- Why not put aside as little as R50 per month into your own medical savings fund? (MEDIMED Alpha option is significantly cheaper than anything else on the market and you could keep some of this savings to support the times when you need medical treatment).
- If you have a credit card use it. MEDIMED refunds weekly. (if you submit your claim immediately you should get your refund before having to pay your credit card).
- Medication
- Ask your doctor and/or pharmacy for the lowest cost generic. This is because MEDIMED uses the “Maximum Medical Aid Price” (MMAP) as a reference price – this is basically the average of all generics in a particular class of medicine. By asking for the lowest cost generic the price will be within the benefit paid by MEDIMED, otherwise you will have to pay in extra.
- Obtain your medicines from a “recommended pharmacy”. These are pharmacies who have undertaken to charge a dispensing fee at the same level as the MEDIMED dispensing fee benefit. A list of these pharmacies is available from the MEDIMED customer care team. Alternatively, Clicks pharmacies are also recommended pharmacies.
Medisave Max and Standard are both options that have savings accounts attached to the day-to-day benefits. Members should therefore manage their day-to-day expenses carefully to ensure that there are enough benefits to last for the full year. Members should also study their benefit guides carefully as there are certain measures that were put in place to ensure that members’ savings accounts last longer i.e. the “preventative care benefit” as well as a list of procedures that will be paid from the Scheme risk instead, if pre-authorised. Please contact the customer care team for more information.
The Medisave Essential option is a capitated option, where your selected practitioner is the key to your healthcare requirements. There are no limits on consultations, medication, radiology, pathology, etc. Medication is prescribed in accordance with a medication formulary. It is therefore not necessary for a member to manage his/her costs as the provider controls and manages the costs. This option is unfortunately only available to members that reside in the Nelson Mandela Metropole.
Members should never assume that the Scheme has received an account, even if the provider has indicated that the account is for member information purpose only. Always forward the copy to the Scheme as well. Study your claims statements to ensure that claims were paid from the correct benefit and that you have in actual fact received the services / medication that a provider has claimed for.
MEDIMED members need to submit the following for claims to be processed effectively:
- Detailed Account (Patient name, medical scheme number, service date, tariff code/s & claimed amount are all important information needed on the account).
- A receipt for all medical expenses paid upfront (Remember that all medical expenses up to R650, except hospitalisation and chronic medication, must be paid upfront for members on the Alpha option).
- Pharmacy claims must include the invoice and a receipt/cash register slip (PAID stamp on invoice is not sufficient).
This will ensure that members are refunded timeously and are not unnecessarily out of pocket for any length of time.
Aside from excellent value for money, MEDIMED refunds members weekly, which helps members with their cash flow. The payment runs are every Thursday and members will have the refunds in their bank accounts on the following Tuesday (at the latest) should we have your banking details on our system.
As providers on the Alpha option get paid up-front and do not have to wait for payment they have a good perception of the Scheme.
MEDIMED made a surplus of R8.5 million as at 31 December 2012 and the scheme’s reserves as at this date is R124 million (101.72%). (The requirement from the Registrar of Medical Schemes is 25%).
The average annual increase for 2014 will be 6.63%, which is below wage and salary increases.
We trust that the scheme will continue to perform this well in 2014.