Frequently Asked Questions

Your health needs change and your plan must be adjusted in line with these changes. You might encounter sudden health issues which require specific treatment and changes to utilise maximum cover. You might need to change to a new Medical Scheme - a process your Broker will handle. You encounter problems and do not know how to resolve it. Your Medical Scheme ran into financial trouble or are amalgamating, and you feel in the dark.

You choose to opt for Hospital Cash Back Options or Hospital Insurance options and are unaware of the pitfalls or shortcomings. You feel overwhelmed and do not know what changes were made to your Medical Scheme and are using outdated information. You feel Medical Schemes are complicated and you are confused with the variety of options available.

You chose a Scheme but do not know how to apply and implement the option you chose. You do not know how to claim and have many questions which you struggle with. You do not understand the terminology used and are unaware of certain benefits and Networks or limitations. You encounter shortfalls and co-payments and are unaware of top up products or added cover.

Your CMAC Advisor will provide details and advice to ensure your cover is best suited to your needs. They will negotiate on your behalf and resolve escalated disputes. They will keep you well informed, explain terminology, and warn you in advance to assist should you need to change, keep you informed of structure and benefit changes and counteract the flashy advertising campaigns pointing out any short comings.

They will communicate annually when Schemes allow members to change options and assist with advice and processing of changes and enable you to make an informed decision to ensure you are covered optimally at the most affordable premium. They will keep you abreast of applicable Networks and limitations to ensure optimal usage, provide information regarding shortfalls and Gap Cover as well as added benefits such as Dental Insurance or Day-to-Day benefits, or any other products which might benefit you.

They will assist you with a needs analysis, quote, advice and application and are often able to negotiate underwriting and discount premiums for certain products, not only for Groups but also for Individuals. Whether you’re a large family, student, retired or a Corporate Group, trust your CMAC Advisor to assist you to find a tailored plan to your needs and pocket.

Therefore, it cannot be stressed enough to ensure you choose a well experienced and trustworthy CMAC Advisor who are fully accredited, who you can rely on, build a professional relationship with and who can make the entire experience painless and rewarding.

Medical Scheme Brokers come at no extra cost to a member, they earn a regulated commission directly from the Medical Schemes. This commission is already priced into a member’s monthly premium which won’t decrease in the absence of a Broker/Advisor. Certain Brokers/Advisors might charge a fee for additional services with the consent of the client in line with Legislation.

CMAC can assist any member be it as an Individual in Private Capacity or as a Group Member part of an Employer group. Our skilled Advisors are equipped to deal with Individuals, SME’s and Corporate Groups. All though it is one fit for all, we treat each client as a unique entity with respect and integrity. We adapt to their needs.

Prescribed Minimum Benefits (PMBs) are a set of defined benefits ensuring all medical scheme members have access to certain minimum health services, regardless of the benefit option selected. The aim is to provide people with continuous care to improve their health and well-being and to make healthcare more affordable. Medical scheme members with PMB conditions are entitled to the specified treatments and these must be covered by their medical scheme subject to specific protocols, formularies and guidelines, even if the patients were treated at a state hospital.

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

• emergency medical condition;
• a limited set of 271 medical conditions (defined in the Diagnosis Treatment Pairs); and
• 27 conditions (defined in the Chronic Disease List).

• Addison's disease
• Asthma
• Bipolar mood disorder**
• Bronchiectasis
• Cardiac failure
• Cardiomyopathy
• Chronic obstructive pulmonary disorder (COPD)
• Chronic renal disease
• Coronary artery disease
• Crohn's disease
• Diabetes insipidus
• Diabetes mellitus type 1
• Diabetes mellitus type 2
• Dysrhythmias
• Epilepsy
• Glaucoma
• Haemophilia
• Hyperlipidaemia
• Hypertension
• Hypothyroidism
• Multiple sclerosis
• Parkinson's disease
• Rheumatoid arthritis
• Schizophrenia
• Systemic lupus erythematosus (SLE)
• Ulcerative colitis

*Hormone Replacement Therapy (PMB Cover)(Menopausal Management)

* *Will only be covered when an algorithm has been developed.

Your medical scheme may choose a healthcare provider or group of providers (doctors, pharmacists, hospitals, network, or so on) to be the preferred provider or providers to its members when they need diagnosis, treatment, or care for a prescribed minimum benefit (PMB) condition.

If you do not use the designated service provider your scheme has chosen, you may have to pay the costs yourself, or your scheme may only pay as much as it would have cost you to make use of the designated service provider, and you will have to pay the difference.

Your scheme cannot charge you a co-payment or levy on a prescribed minimum benefit (PMB). However, if your scheme appoints a designated service provider and you voluntarily use a provider other than a designated one, your scheme may charge you the difference between the actual cost and what it would have paid if you had used the designated service provider.

It is seen as a safety net covering short payments by a Medical Scheme. It assists members with out of pocket expenses relating to short payments and co-payments. It is a short term insurance product that covers the difference ("gap") between what medical specialists and providers charge and the rate your medical aid pays, often up to 500% or 700% of the scheme tariff. Typical claims would be for in-hospital co-payments, deductibles, and tariff shortfalls, preventing high out-of-pocket expenses and can be added to any Medical Scheme Option. Benefits and Added Benefits would be subject to the Specific Provider and Option.

To assist you with Medical Scheme short payments, co-payments and deductibles. Cover would include but are not limited to:

• Service providers such as specialists, surgeons, anaesthetists etc. who charge more than the medical scheme tariff for authorised in-hospital procedures and specified authorised out of hospital procedures.
• Out-patient chemotherapy, radiotherapy, and kidney dialysis.
• Hospital co-payments and fixed co-payments for specific procedures in or out of hospital e.g. MRI and CT Scans, Ultrasounds, Scopes etc.
• Sub limit cover.
• Short falls or penalties related to the use of a non-DSP or out of network provider.
• Charges above the Medical Scheme tariff for hospital costs e.g. cost of bed, food, bandages etc.
• Certain procedures not covered or declined by the Medical Scheme e.g. wisdom teeth removal, hip replacement, joint replacement, hernia repair etc. (available through specific gap providers on their exact gap options).
• Accidental cover, Emergency Illness and Emergency Room Cover.
• Cancer Cover and Cancer Diagnosis Cover.
• Other benefits such as Gap and Medical Scheme Premium Waiver Cover, Step Down Cover, Trauma Counselling, Baby Benefit etc.

*Cover will vary depending on the provider and option you choose. Certain benefits are only available on certain options.

It is a Short Term Insurance Policy which covers medical treatment cost as a stated benefit. The insured are reimbursed or the provider is paid directly. Benefits could be a fixed sum of money per day or a maximum sum of money for a specialised health event. It by no means replaces Medical Scheme cover and can be added as a Top Up product to any Medical Scheme Option to cover day-to-day expenses such as Doctors visits, Prescribed Medication, Optometry, Pathology, Chronic Medication etc. or it can be purchased as a stand-alone product to cover not only day-to-day expenses but also Hospital expenses and Emergencies. Some Providers only cover Accidental events in Hospital v. others may cover Accidental as well as Maternity and Illness.

It is a cost effective alternative for members who cannot afford Medical Scheme premiums to ensure they still receive ample private cover for their health needs. It also assist members who can only afford a Medical Scheme Hospital Option to receive day-to-day cover by adding primary cover to their Medical Scheme Hospital Option.

They are regulated under different Acts and Regulatory Bodies and provide different levels of cover.

Medical Schemes: Members pay the same premium depending on the plan and family structure e.g. number of dependents and their age such as an adult or a child. LJP’s (Late Joiner Penalties) may be applied. Medical Schemes provide comprehensive (generally unlimited) coverage for dreaded diseases; are accepted by all private hospitals (emergency) depending on the scheme benefits package or network hospitals (elective), and hospital pre-authorisation required. Medical Schemes cover in-hospital benefits according to the Scheme Tariff, day-to-day medical expenses depending on your chosen plan and benefits and fully covers PMBs and CDL’s (PMB chronic conditions). Premiums may not be negotiated (regulated premiums). Can add Gap Cover to assist with short falls. May not restrict entry age.

Health Insurance: Premiums are risk-rated and policy holders entering after a specific age might pay a higher premium than policy holders entering at a younger age, provided that all policy holders with the same age pay the same premium – Late Joiner Penalties may not be applied. Provide a lump sum or daily rand amount for hospitalisation, are accepted by most private hospitals or network hospitals where stipulated and hospital pre-authorisation is required. Health insurance covers your day-to-day medical expenses depending on your chosen plan and/or covers the cost of a specific medical procedure or hospital event but does not have to provide cover for PMBs and CDL’s (PMB chronic conditions). Premiums may be negotiated typically for Employer Groups. Cannot add Gap Cover. May restrict entry age.

It is a health insurance policy that is designed to assist you and your family in funding the high cost of private dentistry.

It provides a solution for Medical Scheme members as well as members who are not covered by a Medical Scheme (as a stand-alone product), to fund their dentistry treatment costs. Because most Medical Scheme options do not cover dental treatment costs in full or provide limited cover, members opt for Dental Insurance either as a Top Up or a Stand Alone product.

It would cover day-to-day procedures such as fillings, extractions and scaling but may also include specialised dentistry such as crowns, implants and bridges.

It is a Short Term Insurance policy which covers your furry family for unexpected vet costs, accidents and illnesses ensuring they are always taken care of and seen to. Cover depends on the option you choose and may include but are not limited to in room surgery cost, hospitalization, medication, loss of pet cover, and routine cover.

It is a Short Term Insurance policy which covers you for unexpected losses whilst travelling for leisure or work (business). It would include but are not limited to cover for medical emergencies, trip cancellations, delays, personal liability, loss of luggage, accidental death etc. There are various products to suit your needs such as Top Up Cover (for Medical Scheme members or Bank clients, who receive cover through their Medical Scheme or Bank and covers events not covered by the Medical Scheme or Bank Policy), Business Travel (Manual labour included or excluded), Student Cover, Ex-Pat Cover and many more.

It is important for any traveller to consider Travel Insurance to protect themselves against unexpected financial losses be it for Leisure or Business. We also offer Corporate Cover for Corporate Groups.

Speak to your CMAC Advisor to assist or contact info@cmac.co.za