Click on the questions below to read the answers.
SAMWUMED pays for treatment and medication of all PMB’s (a list of 270 deceases issued by the government, including chronic illnesses like asthma). You have to first be registered though, by your doctor, onto the Scheme’s Chronic Disease Management Program. In other words, you do not use your day-to-day benefits to treat a chronic illness.
There is no restriction to which GP you may use. SAMWUMED members can go to any doctor.
In cases of emergency a member can go to any nearest private hospital to receive medical attention and receive treatment.
Yes, to SAMWUMED you can add your girlfriend or boyfriend as your life partner. Besides their copy of identity document, the Scheme will require a written affidavit confirming relation to you the main member.
Unfortunately, siblings do not qualify as dependents. Only your spouse, your girlfriend or boyfriend as your life partner, child, grandchild, parent, and grandparent do qualify.
Your new-born baby should be registered within 30 days of birth. There is no waiting period for a new born baby if registered with the Scheme within 30 days of birth.
If you were registered in another medical scheme in the past 90 days for at least 2 years, benefits will be activated from the joining date, as soon as your application is successful. Secondly, if you join the scheme with no previous medical scheme membership, the waiting period is one month from the join date and 12 months for pre-existing conditions.
No, subsidies are conditions of employment and the Act does not address such conditions.
The rate at which the Scheme pays for health services to service providers on behalf of members. It is based on the National Reference Price List published by the Department of Health.
A healthcare provider or group of providers that the Scheme has chosen to provide certain medical care for Prescribed Minimum Benefits.
Yes, in terms of the open enrolment principle a member may join any open medical scheme of his/her choice.
Application forms must be completed by providing all the information requested by the scheme honestly and with the necessary details required. If you are unsure ask your broker or the medical scheme to assist you. Ignorance is not an excuse in law and members who do not provide the correct and truthful information about their pre-existing conditions risk having their membership cancelled.
Yes. On the grounds of failure to pay membership fees timeously or other debts owing to the scheme, submission of fraudulent claims, committing other fraudulent acts, or the non -disclosure of material information.
No. The Act prohibits the payment of dividends, bonuses, rebates or re-funding of any portion of contributions. Benefits may also not be carried over to the next financial year. Savings accounts on the other hand are carried over to the next year and paid out to members when they leave the medical scheme and join another scheme without a savings option.
This is the part of the account that a member might have to pay out of their own pocket where benefits do not cover the treatment or medication received.
All three categories mentioned above concerns employment. If you are on an open medical scheme your membership may not be terminated based on any of the scenarios provided that your contributions are paid timeously.
As far as restricted schemes are concerned, such as SAMWUMED, you have to meet the eligibility criteria. The eligibility criteria is concerned with your employment. Therefore, you may only belong to SAMWUMED for as long as you are employed within a Municipality. If you are retrenched, you may no longer belong to the Scheme. You will have to join another open medical scheme of your choice. However, if you retire you may stay on as a SAMWUMED member and you will be regarded as a continuation member.
Yes, it remains a member’s responsibility to ensure that his/her employer timeously pays the correct contributions to the Scheme, as per Scheme Rules.
Yes. A member remains liable for full contributions for the whole notice period regardless of whether they serve the termination notice or not. SAMWUMED may institute legal proceedings to recover outstanding contributions or backdate the termination to the last date of contributions received.
Yes, until the last day of membership provided contributions are being paid as SAMWUMED is an arrears paying scheme.
Yes, SAMWUMED requires a notice period of one (1) calendar month. Contributions must still be paid in full, until the last effective date of membership.
Yes, without any break in membership and provided contributions are paid. It is important to inform the Scheme if one chooses not to continue. Such members are referred to as continuation members and one of the dependents (usually the surviving spouse) will become the principal member. In the instance that the deceased member belonged to a restricted medical scheme, such as SAMWUMED, no additional dependents will be allowed on the medical scheme as the link between the scheme and the person who met the eligibility criteria has been broken. For example, if the principal member dies and his wife becomes the main member she cannot add her new husband as a dependant and they will have to join an open medical scheme.
No. A medical scheme may not refuse admission of a member’s dependant if such a dependant meets the eligibility criteria stated in the registered rules of the scheme.
Yes, with the assistance of his/her parents or legal guardian, provided that the relevant contributions are paid by him/her or on his/her behalf. Such a minor will be registered as a principal member and not as a child dependant.
No. It is illegal to belong to more than one medical scheme at a time. Section 28(a) of the Medical Schemes Act prohibits this. Members must ensure that their membership on a former medical scheme is duly cancelled before undertaking membership with a new medical scheme. Ensure that your last date of membership with the one scheme is not after the effective join date with your new medical scheme.
Yes the open enrolment principle means that any person can join any medical scheme of their choice. The only exception is restricted medical schemes, like SAMWUMED where you can only join if you meet the eligibility criteria. Eligibility criteria must be based on the grounds provided in the Act and which includes employment or membership of a particular employer, profession, trade, industry, calling, association or a union which has established a scheme exclusively for its employees or members. In the case of SAMWUMED the Scheme caters for employees from local government (municipalities) and associated agencies.
Ensure that you understand how the benefit options work and select according to your healthcare needs and what you can afford. The Prescribed Minimum Benefits (PMBs) must be included in every benefit option. The registered rules of medical schemes fully disclose detailed information regarding the relevant benefits and contributions. – Click here for SAMWUMED Scheme Rules
Ensure that the scheme is duly registered in terms of the Medical Schemes Act 131 of 1998. Only entities that are registered by the Council of Medical Scheme (CMS) can do the business of a medical scheme. The names addresses and telephone numbers of all registered schemes are published on the website of the Council for Medical Schemes. The address is: http://www.medicalschemes.com/MedicalSchemes.aspx.
If you do employ the services of an agent, broker (intermediary), ensure that he/she has been accredited by the Council for Medical Schemes (CMS). To ascertain whether a broker has been accredited, prospective members should insist that brokers produce proof of accreditation with Council and/or verify the broker accreditation status on: http://www.medicalschemes.com/AccreditedBrokers.aspx
No. There is no such provision in the Act. One can apply directly to the scheme or opt to use the services of a broker (intermediary).
Prescribed Minimum Benefits (PMB) is a set of defined benefits that ensure members have access to certain minimum health services, regardless of the benefit option they have selected. In accordance with the Medical Scheme’s Act, medical schemes have to cover the costs related to these conditions which include:
- Any emergency medical admission
- A limited set of 270 pre-defined medical conditions
- Twenty-five (25) chronic medical conditions
- Your doctor will guide you in determining whether your condition falls into one of the PMB conditions. It is vital that you obtain a pre-authorisation for any PMB condition as your scheme may require you to be referred to a designated service provider so that all associated costs are in line with SAMWUMED’s Scheme Rules.
In the case of an emergency situation a member or a family member may pre-authorise the admission on the first working day after being admitted.
By calling 0860 33 33 87 (preferably 72 hours before the procedure is performed) and provide the following information:
- Membership number
- Patient’s name, surname and date of birth
- Doctor’s name and practice number
- Name of hospital
- Procedure to be performed and ICD-10 code(s)
- Date of admission
- For any procedures or treatments that clinically require admission to a hospital
- For specialised radiology (x-rays) in-and out-of-hospital (MRI and CT Scans)
- For Oncology (cancer) Treatment
- For Renal Dialysis (cleaning of kidneys)
- For clinically appropriate home nursing, admission to a step-down facility and rehabilitation
- For Maternity admissions and confinements
Pre-authorisation for hospital admissions and certain out-of-hospital care is a key component in managing access to affordable, appropriate, safe and quality health care. Medscheme’s pre-authorisation requests are assessed against clinical and funding guidelines as well as set criteria that recognises healthcare providers who are able to perform certain procedures. Once pre-approval is made, the healthcare provider and hospital account will then be paid according to the selected benefit option and available benefits.