How do I become a MedXpert client?

If you are the principal member of an open medical scheme in South Africa, then you qualify. To sign up, you need to sign an appointment letter which will instruct the medical scheme that you are represented by MedXpert who will represent you as healthcare broker. This will also give MedXpert permission to obtain access to your medical scheme information so they can assist you with queries and provide support.

What does it cost?

Whether you appoint a medical scheme broker or not, there is commission built in for such services in your monthly medical scheme premium.This appointment of a healthcare broker will not impact any other intermediary appointments you have made for assistance on other insurance or financial products.

There is also the option for you to become a MedXpert Private Client at a nominal monthly fee, which gives you access to exclusive and highly specialised services such as dispute resolution and a dynamic needs analysis to ensure you’re health cover needs are met.

What is Prescribed Minimum Benefits (PMBs)?

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.

The Prescribed Minimum Benefits is a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected.

The aim is to provide people with continuous care to improve their health and well-being and to make healthcare more affordable.

What is an emergency condition?

An emergency medical condition is a sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or an operation.If the treatment is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death.

In an emergency it is not always possible to diagnose the condition before admitting the patient for treatment. However, if doctors suspect that the patient suffers from a condition that is covered by PMBs, the medical scheme has to approve treatment. Schemes may request that the diagnosis be confirmed with supporting evidence within a reasonable period of time

Annexure A of the Regulations to the Medical Schemes Act provides a long list of conditions identified as Prescribed Minimum Benefits. The list is in the form of Diagnosis and Treatment pairs (DTPs).

A DTP (Diagnosis and Treatment Pairs) links a specific diagnosis to a treatment and therefore broadly indicates how each of the approximately 270 PMB conditions should be treated. The treatment and care of PMB conditions should be based on healthcare that has proven to work best, taking affordability into consideration. Should there be a disagreement about the treatment of a specific case, the standards (also called practices and protocols) in force in the public sector will be applied.

Scheme exclusions are not applicable to PMB. Medical schemes often have a list of conditions (eg. cosmetic surgery) for which they will not pay, or circumstances (eg. travel costs and examinations for insurance purposes) under which a member has no cover. These are called exclusions.

Exclusions, however, do not apply to PMBs. For example: If you contract septicaemia after cosmetic surgery, your scheme has to provide healthcare cover for the septicaemia part because septicaemia is a PMB. (However the cSosmetic surgery remains an exclusion.) PMBs are concerned about the diagnosis; it doesn’t matter how you got the condition.

What are these Designated Service Providers (DSPs) my medical scheme refers me to?

A Designated Service Provider (DSP) is a healthcare provider (doctor, pharmacist, hospital, etc.) which is a medical scheme’s first choice when its members need diagnosis, treatment or care for a Prescribed Minimum Benefit (PMB) condition.

If you choose not to use the DSP selected by your scheme, you may have to pay a portion of the medical bill as a co-payment/penalty. This could either be a percentage co-payment or the difference between the DSP’s tariff and that charged by the service provider you chose to use. Medical schemes have to ensure that it is easy for beneficiaries to get to the DSPs. If there is no DSP within reasonable distance of your work or home, then you can visit any provider and the scheme is obliged to pay.

When you suffer an emergency condition, or are involved in an accident, you may go to the nearest healthcare facility for treatment, even if it is not a DSP. Your scheme will have to cover the costs.

Schemes also have to ensure that the DSPs of their choice can deliver the services needed and without members having to wait unreasonably long. Where a DSP is unable to accommodate or treat a member, the medical scheme remains liable for all the costs of treating the PMB condition at a non-DSP.

The State’s healthcare facilities can be, but are not necessarily, DSPs. Before they can be listed as such, schemes have to make sure that their beneficiaries can get to the facilities and that the required treatment, medication and care are available and accessible.

Treatment at DSPs can be handled in two ways:

  • Schemes can insist that you go to a DSP as soon as your condition is diagnosed, in which case they cover the costs from the start. Treatment at a DSP will be covered in full by the medical scheme under the PMB conditions when delivered according to scheme protocols and formularies.
  • If your benefit option allows for this, you can be treated by the doctor of your choice. If you choose to use a provider of your choice for these services, the scheme may apply a co-payment, as registered in their rules.