A benefits package designed for whom

Sick Leave Bank The Sick Leave Bank at FIT has been established to help an employee who is or has a family member that is incapacitated and whose sick, personal, and vacation leave have all been exhausted. The Sick Leave Bank program is a voluntary, confidential program created to provide its members the opportunity to remain in full-pay status and to provide continued pay deductions for payment of benefit premiums.

A benefits package designed for whom

A benefits package designed for whom

The diseases that have been chosen are the most common, are life threatening, and those for which treatment would improve the quality of the member's life. What is a designated service provider?

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, A benefits package designed for whom 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.

If your scheme expects you to use a designated service provider, it must inform you and the rules of the scheme must also state which service providers are the designated ones and what the scheme will or won't pay if you use a provider other than the designated one.

The Council for Medical Schemes believes that if your scheme does not appoint a designated service provider, you are entitled to obtain a service listed in the PMBs from any provider and the scheme must pay.

When can I use a doctor, pharmacist or hospital other than a designated service provider? The regulations provide for instances in which it is not possible for you to make use of the designated service provider for the diagnosis, treatment or care of a prescribed minimum benefit PMB condition.

For example, if you need treatment very urgently. In this case you will be regarded as having obtained the service involuntarily and the scheme will have to pay.

The three cases in which you will be regarded as having obtained the service involuntarily are: 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 schemes to enter into contracts with any designated service provider they choose, especially state hospitals, to ensure that these providers can supply the necessary services.

Many state hospitals have set up separate wards, designed to serve members whose treatment and hospital stay is paid for by their medical scheme and to whom the hospital can afford to provide better service. Other schemes have made arrangements with private hospital and certain retail pharmacies to treat their members.

Yes, medical schemes can make a benefit conditional on you obtaining pre-authorisation or joining a chronic medication 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.

A benefits package designed for whom

Can my scheme insist that it will only fund treatment that follows the appropriate protocol? The minimum standards of treatment for all prescribed minimum benefit conditions have been published in the Government Gazette, and are known as treatment algorithms benchmarks for treatment.

Your scheme may decide what treatment it will pay for for each chronic condition, but the treatment may not be below the standards published in the treatment protocols. If your scheme's cover conforms to that standard and you and your doctor decide that you should follow a different treatment regimen, then you may have to pay towards the cost of that treatment.

Can my scheme refuse to cover my medication if I need, or want, a brand other than that which the scheme says it will pay for? It may refuse to cover all the expenses. Your scheme may draw up what is known as a formulary - a list of safe and effective medicines that can be prescribed to treat certain conditions.

The scheme may state in its rules that it will only cover you if your doctor prescribes a drug on that formulary. Often the medicines on the list will be generics - cheaper copies of the original brand name drug.

If you want to use a brand name medicine which is not on the list, your scheme may refuse to pay for that medicine, or it may foot only part of the bill and you will have to pay the difference between the price of the medication you use and the one on the formulary.

If you suffer from specific side effects from drugs on the formulary, or if a substituting drug on the formulary with one you are currently taking affects your health detrimentally, you will be able to put your case to your medical scheme and ask the scheme to pay for your medicine. Generally, however, it is likely that the scheme will expect you to stick to the medication on the formulary.

Can my scheme make me pay for a PMB from my savings account? No, the regulations state that schemes cannot use your medical savings account to pay for prescribed minimum benefits PMBs. Some schemes, especially those that have appointed state hospitals as their designated service provider, are suggesting that members who do not want to use the designated service provider, or members who want to take medication not included on the scheme's formulary, can use their savings accounts to pay for this medication.

The Council for Medical Schemes regards this as a contravention of the law. Can my scheme make me pay a co-payment or levy on a PMB? No, 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.

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Your Minimum Benefits Package - CMS

IPM MEMBERSHIP. If you are eligible for Professional Membership, you may also use professional designations after your name.

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