/ 26 October 2012

Getting to grips with your scheme’s lingo


Designated Service Providers (DSPs) and Networks

Most -medical schemes specify a partner network of hospitals and GPs. Using providers that are not on your medical scheme's DSP or Network could mean that your claim is only partly reimbursed, or rejected altogether.


A medicine formulary is a list of generic and brand name medicines that are preferred by your health plan. It is important to know what is listed on your -formulary to avoid any co-payments, as your scheme may only pay for medications that are on this 'preferred' list.

Open scheme

An open medical scheme is 'open' for anyone to join. There are 26 open medical schemes in South Africa, the largest- being Discovery Health Medical Scheme.

Medical savings account

An amount set aside from your monthly premium that is used for the payment of day-to-day -medical expenses. The balance on this account is paid out to you when you leave the medical scheme.

Prescribed Minimum Benefits (PMBs)

All medical schemes must, by law, provide a set of -medical benefits for a basket of conditions. Your scheme must cover you for 270 conditions and 25 chronic -diseases regardless of the type of cover you have. You should pay close attention to your scheme's rules to ensure that your treatment is covered in full.

Restricted scheme

A restricted medical scheme is restricted to certain- applicants -typically by -virtue of employment or -profession. The Government Em–ploy-ee Medical Scheme (GEMS) is the largest among 71 restricted schemes.

Waiting period

Medical schemes apply a three-month waiting period during which no claims are processed- for ANY medical -procedure or service. Your medical scheme is also allowed to impose a waiting period of up to 12 months based on your medical history. During this time no benefits will be paid out for any costs relating to the identified -previously-existing conditions.

Source: Board of Healthcare Funders (with additions)