The Scheme was registered in 1974 and since then, went through a name change and several benefit restructurings to ensure that it best serves member needs. More than 96%
of our members reside in Middelburg and Witbank.

Alliance Midmed is a traditional scheme with a small savings account and the benefits focus on the quality of, and access to, appropriate health care.

Momentum Medical Scheme Administrators (MMSA) administers the Alliance Midmed Medical Scheme. MMSA has an excellent track record in the administration of closed schemes such
as Alliance Midmed.

THE SCHEME AND ADMINISTRATOR CONTACT DETAILS
The Momentum Medical Scheme Administrators offices are based in Umhlanga and their physical address is:

1-3 Canegate Road
La Lucia Ridge
4019

MMSA staff operates a dedicated share call telephone number for Alliance Midmed. Members can phone the number 0860 002 101 for any matter related to the Scheme. The facsimile number is (031) 580-0480.

The Call Centre is open from 07H00 to 19H00 from Mondays to Fridays, and 08H00 to 12h00 on Saturdays, excluding public holidays. Alliance Midmed retains the services of a Scheme Consultant in Middelburg. Ronelle Westermann is based at the Columbus Stainless Time Office and visits the Thos Begbie and Middelburg Samancor site weekly to address members’ specific queries. You can contact Ronelle on telephone number (013) 247-3066, and facsimile number (013) 247-2278.

Once a week, usually on Tuesdays, claims are couriered to MMSA. Members are advised to rather use this facility to get their claims to the administrator. Claims can be left at the medical claims box at your Time Office or be placed in the claims box at Du Buisson and Partner’s office at the Midmed Hospital. If you are unable to access these facilities, please mail your claims and queries to:

Alliance Midmed Medical Scheme,
p/a MMSA,
P O Box 2338
Durban
4000

ALLIANCE MIDMED MEDICAL SCHEME CONTACT INFORMATION

 

IMPORTANT NOTE:
The Europ Assistance Call Centre has a medical doctor on duty 24/7/365.
• The doctor is a back-up for skilled agents and they can telephonically assist with any emergency.
• The team assists you telephonically while dispatching emergency personnel to you.
• The operators can deal with emergencies, including poisoning, electrocution, rape, shock and unconsciousness, etc.

SUBMITTING CLAIMS:
Ask the service provider to submit accounts electronically. It is cheaper and more accurate.

If the service provider refuse to submit electronic claims, then please:
• Place the claims in the medical aid box at your Time Office,or
• Place it in the Alliance Midmed box at Du Buisson & Partners at the Midmed Hospital building, or
• Post to Momentum Medical Scheme Administrators,
PO Box 2338, Durban, 4000.

MEMBERSHIP
On joining one of the participating companies, both you and your family may join Alliance Midmed.

WHEN MAY I NOT JOIN THE SCHEME?
The Medical Schemes Act does not allow membership of more than one Scheme at a time. Should you or your dependants belong to another Scheme already, you may not join Alliance Midmed. Similarly, if you are not employed by one of the participating companies, you may not join the scheme.

HOW DO I REGISTER AS A MEMBER?
On the date of your employment, please contact your Human Resources department for application forms. Your HR contact person will send the completed forms to Momentum Medical Scheme Administrators where your application will be processed. You will be issued with a contract number, membership cards and welcome letter should your application be successful.

WHO CAN BE REGISTERED AS DEPENDANTS?
• Your spouse/partner.
• Your dependent children (including step children and adopted children) who are younger than 21 years of age or handicapped
• Any immediate family for whom you are liable for care and support (e.g. parents or siblings of the principal member).

Please note that specific qualifying criteria must be met, for all special dependants.

WHO CAN CONTINUE THEIR MEMBERSHIP AS CONTINUATION MEMBERS?
Pensioners and their dependants may remain members of the Scheme provided that they meet with the retirement age (unless retired early due to ill-health, or as the Rules may stipulate from time to time), and have been a member of either the Alliance Midmed Scheme and/or another Scheme for five consecutive years.

Surviving spouses may remain members of the Scheme if they:
• are registered as dependants at the time of the member's death,
• can prove that his/ her employer does not provide for medical scheme membership;
• can prove that the deceased principal member had been a member of either Alliance Midmed or another Scheme for a period of five consecutive years. Should the surviving spouse remarry membership of the Scheme will cease.

Pensioners or surviving spouses who wish to terminate their membership must notify the Scheme in writing.

PROOF OF MEMBERSHIP
When your membership application has been processed, you will be issued with a membership card(s). Your membership card reflects your membership number, yours and your registered dependant's names and dates of birth and the dates from when you are entitled to benefits. Please look after your card and do not lend it to anyone as fraudulent use of cards may lead to the suspension or termination of your membership.

2008 BENEFIT STRUCTURE
Alliance Midmed offers a traditional benefit option with a compulsory 10% Personal Medical Savings Account (PMSA). Benefits are paid either through the Major Medical Pool (MMP), the Life Stages Benefit (LSB) and the Essential Day to Day Benefit (EDDB) or through your PMSA.

 

 

WHICH BENEFITS ARE PAID FROM THE MAJOR MEDICAL POOL (MMP)?
Hospitalisation and Chronic Benefit
The MMP covers high cost expenses such as hospital and hospital-related costs, chronic medication, certain disease management programmes such as oncology, renal dialysis, specialised procedures, chronic medication, etc.

In addition, day to day expenses will be paid from the MMP, including general practitioner consultations, specialist consultations and acute (pharmacy) medicines. There are specific limits for the above benefit items that are determined according to family size. The benefit schedule found in the centrefold of this handbook contains further details.

THE MMP and DAY TO DAY benefit pays claims at the NHRPL or the Alliance Midmed rate unless otherwise stated in this handbook.

MMP benefits are managed through the following mechanisms:
1. Pre-authorisation for hospitalisation, etc.
2. Benefit category limits for consultations, medication, mental health benefits, etc.
3. Management programmes such as the Chronic Care Network (CCN) and a dental management programme.

Life Stages Benefit (LSB)
This benefit consists of early detection and prevention tests which will be paid for from the MMP. It will not affect your out of hospital benefits or savings. Specific tariff codes form part of this benefit and the benefit will be granted once you meet criteria as determined in the table that follows.

 

Benefit	Tariff Code	Frequency
Compulsory Baby Immunisations	Applicable nappi code	As per Department of Health Baby Immunisation schedule
Flu Vaccine	Applicable nappi code	For members over 60 years of age and or high risk members. (once per year)
Pneumococcal Vaccine	Applicable nappi code	For members over 60 years of age and or high risk members
Tetanus Vaccine	Applicable nappi code	Once per year when necessary
Pap Smear	4566	Female 15 years and over once per year
Prostate Test	4519	Every 2 years for men over 40
Blood Sugar Test	4050	All members once per year
Cholesterol Test	4026, 4027, 4028 or 4147	All members over 25 once per year

Essential Day to Day Benefit (EDDB)
The EDDB supplements expenses not covered by the MMP for members' out of hospital expenses. The EDDB allocated per family is limited according to family size. This benefit may be utilised for out of hospital expenses prior to the Personal Member Savings Account being used.

Claims will be paid at the NHRPL (National Health Reference Price List) Rate only and any unused EDDB shall NOT carry over to the following year. The EDDB will be pro-rated for members that do not join the scheme in January.

THE PERSONAL MEDICAL SAVINGS ACCOUNT (PMSA)
In addition to the benefit limits covered by the MMP and the EDDB, members have a compulsory PMSA of 10%. The PMSA also covers the costs of medical expenses not included in the MMP when the EDDB is exhausted.

ACCUMULATED PMSA BALANCE
At the end of each year unused PMSA monies are carried over to the next year as an accumulated PMSA balance. The accumulated balance together with the additional 10% level of savings will be used to pay for your day-to-day claims at NHRPL rates.

CONTRIBUTIONS
1. The Scheme’s contribution table can be obtained from the contact centre.
2. Please note that it is important to check with your employer if your Scheme contributions will be subsidised, and at what rate.
3. Please note that the Scheme bills your contributions at the end of the month for which you have recieved benefits. It is important to pay contributions promptly.
4. Please note that the Scheme functions on a calendar month basis. We will therefore not be in a position to charge contributions proportionately for members that do not commence membership at the begining of the month.

Member portions such as the difference between NHRPL (National Health Reference Price List) and/or the Alliance Midmed and private rates may be paid from the Accumulated PMSA Balance. You may also use the Accumulated PMSA from the previous year to fund Scheme exclusions with the approval of the Board of Trustees. Note however that consultation co-payments will not be funded by either the Scheme, or from the current year’s PMSA Balance.

Your positive PMSA balance earns interest.

If you leave the Scheme, you will receive the PMSA Balance after a period of five months. As per legislation the positive PMSA Balance must be transferred to your new Medical
Scheme if it has a Savings Account.

Whether you resign from the Scheme and are still employed by your company, a five-month waiting period for your savings refund will still apply. This refund to you is taxable and therefore you must declare it if not transferred to another Medical Scheme.

If the claims paid out of your PMSA exceed your contributions up to the date of leaving the Scheme, the shortfall will be recovered from you. Such shortfall will firstly be recovered from the balance available in your PMSA and, if insufficient, it will be recovered directly from you.

If you join Alliance Midmed any time after January in a calendar year, your benefits will be adjusted proportionately.

VALUE-ADDED FEATURES
Pharmacy Advised Therapy (PAT)
Did you know that you can obtain schedule 0 and 1 medicines directly from your pharmacist without a doctor’s pescription. These medicines are typically for mild sore throats, colds, a mild cough or any similar ailment. Ask your pharmacist to prescribe the medicine directly. This benefit can be claimed through the Pharmacy Advised Therapy (PAT) allowance that is available to you. The costs of PAT medicines are deducted from your Essential Day to Day Benefit or PMSA and the advantage is that you save on the cost of a consultation with your doctor. If the condition does not improve after using PAT medicines, please consult your doctor immediately.

Life Stages Benefit (LSB)
As mentioned earlier, Midmed offers members the benefit of having certain tests and vaccines paid from the MMP under this benefit. These costs will not affect the benefit category limits provided that members notify the call centre prior to accessing the services.

Medical Emergencies And Trauma Benefits
The Trauma benefit provides assistance when a member or dependant is involved in a medical emergency, specifically related to violence or an accident.

There are many situations that can cause a deeply distressing experience in a person’s life, leading to emotional shock and physical harm. It is generally accepted that trauma arises from incidents or circumstances much of which is violent.

Non-violent incidents or circumstances generally have an onset period and are covered in terms of Scheme rules. The Trauma Benefit focus on any violent and/or sudden onset of traumatic experience where physical and psychological harm and distress is experienced.

Please note that the normal exclusions in terms of self-inflicted or third party injury or damage prevail.

Cover is available 24/7/365 for the trauma benefit.

The benefit is intended to cover assistance at the time of an event or incident, the evacuation of the injured and traumatised and limited after care. It typically relates to vehicle accidents, assaults & attack, hijacking, child abuse, house breaking, armed robbery, theft and family violence and animal attacks.

EMERGENCY MEDICAL ASSISTANCE PROGRAMME
Alliance Midmed contracts with a national emergency services provider to assist members in emergency situations.

To activate this service, call the share-call number 0860 255 426 (ALLIAN(CE)). It is important to note that you have to call this number to authorise the emergency transportation, even if you are Middelburg or Witbank based.

Through the Emergency Call Centre you have access to a comprehensive 24-hour national emergency evacuation and management service, including air-ambulances. If you have an emergency and, for some reason, cannot contact the Emergency Contact Centre, you have 24 hours to do so. Should another service provider be contacted and deliver a service, without the authorisation of the Emergency Call Centre, you risk the claim not being paid by the Scheme. If you are involved in a medical emergency, the Emergency Call Centre will provide you with the following services, subject to the limitations as follows:

EMERGENCY SERVICES
Medical transportation – The Emergency Call Centre will arrange and pay for emergency medical transportation as:
• Deemed appropriate by their Doctor, (subject to NHRPL rates).
• Emergency medical advice and assistance and information hotline.
• Medical repatriation (transport to another medical facility).
• Escorted return of minors.
• Inter-hospital transfers and compassionate visits.

When you or your dependants call the Emergency Call Centre, please provide the following information:
• Your name, address and Alliance Midmed membership number.
• The name, place and telephone number where the Emergency Call Centre can reach you.
• A brief description of the medical emergency.

Please note that the Emergency Call Centre will provide assistance but will be under no obligation to pay for the services rendered in circumstances where the medical emergency is:
• Of such a nature as can adequately be treated at or near the place where the medical emergency occurred (not medically justified)
• Such that the member is nonetheless able to travel as a seated passenger in any form of motorised transport, without requiring a medical escort; (not medically justified).
• The result of the intentional and/or deliberate act of the member, committing suicide or any such attempt.
• As a result of any criminal activity by the member.

 

PERSONAL HEALTH ADVISOR SERVICES
In addition, The Emergency Call Centre introduces their Health Access Programme, including Health counseling, an audio health library and service provider selection. You may access these and many other services through the Scheme’s emergency number 0860 255 426 (ALLIAN(CE))

The telephonic services include the following:
• General medical advice and information.
• Advice on chronic conditions (e.g. high blood pressure, epilepsy, etc.).
• Advice on allergies and poisons.
• Advice on traveler’s immunisations and tropical diseases.

POINTS TO REMEMBER
Please ensure that The Emergency stickers issued to you are clearly displayed on your vehicle. Stickers should be prominently displayed on the bottom right corner of your rear windscreen to alert emergency personnel. Please keep a copy of your medical Scheme card in your car's cubby-hole. This is a likely place where paramedic personnel look for identity details upon arrival at an emergency scene. Should you require additional stickers, please contact the Administrator.

REMEMBER:
Phone the Alliance Midmed Emergency number 0860 255 426 (ALLIAN(CE)) in an emergency.

Medication can attack the virus while vitamins, good nutrition and exercise can play a critical role in keeping your body strong and healthy. Starting treatment at the right time improves quality of life and decreases the risk of serious infections or other complications. Aid for AIDS can help you access benefits to assist you with the management of HIV/AIDS. The Scheme has allocated a benefit specifically for HIV/AIDS related medicines.

The benefit allocated by Alliance Midmed is used for the payment of medicines to attack the virus, vaccinations to protect against illnesses such as TB and Flu and vitamins to boost your immune system. If you are HIV positive please register with Aid for AIDS as soon as possible to access this benefit. Aid for AIDS is a comprehensive HIV disease management programme that offers members and beneficiaries access to:

• Medicines to treat HIV (including drugs to prevent mother- to-child transmission and infection after rape or needle stick injury) at the most appropriate time.
• Treatment to prevent opportunistic infections like certain serious pneumonia's and TB.
• Regular monitoring of disease progression and response to therapy.
• Ongoing patient support via a Nurse-Line.
• Clinical Guidelines and telephonic support for providers.
• Assistance in finding a registered counselor for emotional support.

If your test shows you are HIV-positive, join Aid for AIDS by calling them, in confidence, on 0860 10 0646 and ask for an application form. Your doctor can also contact Aid for AIDS on your behalf. Once you have received an application form you and your doctor should complete it and return it to the Aid for AIDS office by using the confidential toll-free fax line indicated on the form. A highly qualified medical team will review your details and where necessary, discuss cost-effective and appropriate treatment with your doctor.

Once treatment has been agreed upon, you and your doctor will be sent a detailed treatment plan, which explains the approved medicines as well as the regular tests that need to be done to ensure that the drugs are working effectively and safely. Every reasonable precaution has been taken to maintain patient confidentiality.

The staff working for Aid for AIDS have signed confidentiality agreements and do not work for the Scheme or the Administrator. They are based in a different city (Cape Town), with a separate telephone, fax and private mailbag facility.

If you are exposed to HIV through rape or a needle stick injury, please ask your doctor to contact Aid for AIDS to authorise special anti-retroviral medication to help prevent possible HIV infection. It is best to take this medication as soon as possible following exposure. If exposure occurs after hours, during a weekend or on a public holiday, make sure that you get the necessary medication on time. You or your doctor can contact Aid for AIDS the following working day to arrange for authorisation of the drugs for payment by the Scheme.
Contact Number : 0860 10 0646
Fax : 0800 60 0773
E-mail address : afa@pbm.co.za

HOSPITALISATION
In the event that either you or one of your dependants is going to be hospitalised, please phone for pre-authorisation on 0860 002 101. You have 48 hours to notify the Scheme after being admitted to hospital. Should you fail to obtain pre-authorisation you will be required to pay R1500 of the hospital account out of your pocket.

Please ensure that you have the following information ready when making the call for authorisation:
• Your membership number.
• Details of dependant requiring the treatment.
• Name and practice number of admitting doctor.
• Name and practice number of referring doctor (where applicable).
• Date of admission.
• Medical condition ICD 10 (diagnosis) code and/or CPT (procedure) code.
• Type of procedure/operation (where applicable).
• Name of hospital or clinic.
• Expected length of stay.

Please note that as the claims are paid according to the details provided, it is essential that you notify the Scheme of any changes to avoid your claim being rejected. Also note that the authorisation does not constitute agreement by the Scheme to pay for the services of any specific provider, and specifically it does not constitute approval by the Scheme to pay above NHRPL rates.

Please note that a R150 co-payment is payable at the hospital if you or your dependants make use of the emergency services after hours. Should you be admitted as a result of this visit, you will not be liable for the co-payment.

MEDICINE BENEFIT MANAGEMENT
Your medicine benefits are valuable. In order to maintain the Scheme’s generous medicine benefit, please be cautious when utilising this benefit on medicines that are unnecessary, inappropriate or simply too expensive compared to other similar products. Every year, the increasing costs of medicines have affected your contributions that have been greater than the average increase in salaries. This means that you as the member are getting less value for your healthcare Rand. The Scheme’s goal is to protect you from the negative effects of increasing healthcare costs without compromising the quality of care.

Medicines account for about 35% of the money spent by the Scheme each year, making it a major cost and it is essential that the prices and usage are carefully managed. We have therefore implemented Maximum Medical Aid Price (MMAP). The MMAP sets a price limit on what the Scheme will pay for any group of medicines that have a similar clinical effect and allows the Scheme to exclude medicines that have not been proven to be of good value.

HOW WILL THE SCHEME’S MEDICINE MANAGEMENT PROGRAMME AFFECT ME?
MAXIMUM MEDICAL AID PRICE (MMAP)
The Maximum Medical Aid Pricing Committee regularly allocates a price group to each group of medicines and makes extensive use of generic substitutes where applicable. These generics comprise of an exact match of active ingredients of the branded product but are substantially cheaper. The MMAP price is set at a best-value-for-money level without compromising quality. Should you as the member opt for the more expensive branded product, where a generic equivalent is available, you will have to pay the difference to the provider at the point of service.

Government have also intervened and established a set price per medicine product and a set dispensing fee (the so-called Single-Exit Price). Alliance Midmed retains the MMAP price, as it sets a realistic price for products within a specific group of medicines. The Scheme will therefore pay the lesser amount of SEP or MMAP.

At least one medicine in each group will be reimbursed fully, and no co-payment will be required other than that which is determined by the Scheme rules. In most instances, at least two or more products are available. This list will apply to both the Acute and the Chronic Medicine Benefits.

CHRONIC MEDICINE PROGRAMME
The Chronic Medicine programme authorises payment of appropriate, high quality and cost-effective medicines.
The following qualifies for access to the Chronic Medicine Programme:
• Medicines for life-threatening illnesses such as insulin- dependant diabetes.
• Medicines used on an ongoing basis to treat disabling chronic illnesses such as rheumatoid arthritis that significantly affect productivity and quality of life.
• In exceptional instances, very expensive short-term medicines that will prevent other expensive treatment in future, such as hospitalisation.

Access to the Chronic Medicines Benefit is restricted and requires a formal authorisation process to be followed. Note that certain "chronic conditions" may not qualify for pre-authorisation. This includes symptomatic conditions that should ideally be treated by lifestyle changes and intermittent medicines used where necessary (e.g. irritable bowel syndrome), or the milder forms of some conditions (for example, cholesterol medicines in otherwise low-risk individuals who should focus on lifestyle changes). You should also note that authorisation of your chronic medicines onto the programme does not constitute a guarantee of payment of above tariff rates.

 

Note that the financial limits for chronic medicines continue in 2008 after careful analysis of the chronic benefit usage.

The day-to-day medicine benefit is paid from the MMP. When chronic medicine is then declined for use on the chronic programme, it will also not be paid from the day-to-day medicine benefit. Your positive PMSA balance may be used to pay for this benefit.

ADMINISTERING THE CHRONIC MEDICINE PROGRAMME
Momentum Medical Scheme Administrators administers the chronic medicines programme through their ChroniCare Network (CCN) programme. If either you or a family member requires chronic medication you will need to do the following:
1. Go to your doctor or take your script to your pharmacy.
2. Should your provider (doctor / pharmacist) wish to register a new chronic condition/ discuss certain medications with the clinical team / make changes to existing medication or make a motivation they are requested to contact the CCN directly on 0860 002101
3. Information pertaining to the condition / drugs such as test results per condition will be required in keeping with the Entry and Diagnostic criteria and Clinical Rules available from MMSA per condition.
4. If all criteria are met, the doctor or pharmacist will be informed immediately of the outcome and the authorisation will be granted. You can claim medication as soon as registration is approved.

If registration of the medication is rejected/ or held in waiting because we await additional information, the doctor or pharmacist will be informed of these reasons.

If you are currently registered you will only be required to renew your application once your authorisation has expired or if you have had a change in the dosage or type of medication that you are taking.You will notice that the process is different to previous years, and that it has changed to a simpler, paperless telephonic process. When your medication is authorised, you will receive a notification from CCN giving you the details of the medicine that has been approved.

It is important to note that your authorisation may extend beyond the validity of the script that your doctor gives you (as scripts are legally valid for 6 months). When your repeat script is complete, you will need to obtain a new one from your doctor to give to your pharmacist. Please ensure that you make copies of the script and retain for your record purposes in the event of changing pharmacies.

Please enquire from CCN which medicines are covered by the Chronic Medicine Programme or the Maximum Medical Aid Price (MMAP). If it is not covered, you will be required to make a co-payment upon collecting your script.

You can access the MMAP information on the following web pages:
www.interpharm.co.za
www.medprax.co.za

GENERIC MEDICINES
Generic medicines have the same chemical ingredients, strength and formulation (i.e. tablet, syrup etc.) as the original product. The Medicines Control Council (MCC) checks each medicine for safety and efficacy before it is registered. Generic medicines offer products that are as effective, but generally cheaper than the original.

Why are generic medicines cheaper than brand name drugs?
Much of the cost of a brand name drug covers the money spent on research and development. Generic Medicines may only come on the market, after the patent protection period for the original drug has expired.

Are generic medicines as reliable as brand name products?
Medicines generically equivalent to a brand name must meet strict manufacturing standards set by the Medicines Control Council. Tests must ensure the product is bio equivalent to the brand name product, which means that it must have the same amount of active ingredient delivered to the body at the same time, to be used by the body in the same way as the brand name product. Generically equivalent drugs should produce the same results as the brand name product if taken correctly according to your doctor’s recommendation.

DENTISTRY: GENERAL, SPECIALISED AND ORTHODONTICS
There are no category or sub-category dental limits, except if authorisation has not been obtained prior to the dental work being done. However; there remains a 25% co-payment on all specialised dentistry (excluding all crown related work, which is limited to a specific number of crowns). Whilst there is no monetary limit the benefit will be closely monitored and physical provider evaluations will be conducted. The Scheme will be applying a strict clinical policy that focuses on appropriate care. This policy is system driven and will allow members to maximise their benefits whilst maintaining a high quality of care.

MATERNITY CARE FOCUS
Alliance Midmed will pay for all related costs from the Maternity Care Programme, according to the tariff rates. It includes consultations and other costs that will normally be charged to your other benefit categories. Expectant mothers will be provided with information and a Maternity Care Journal. We will also pay for antenatal care classes & postnatal care through selected midwives. Note that, to qualify for this benefit, you are required to register with the Maternity Care Programme by contacting us on 0860 002 101.

SUBSTANCE ABUSE
The Alliance Midmed preferred provider for substance abuse treatment is Elim Clinic in Kempton Park, telephone number (011) 975-2951. Costs for treatment at Elim Clinic will be fully covered, provided that pre authorisation is obtained from the Scheme. Members may also use the services of SANCA when the Elim Clinic is not available, and where SANCA approved institutions provide in-patient and outpatient treatment for drug and alcohol addiction.

 

 

The facilities are available subject to members meeting the criteria as stipulated by the institution. In institutions other than the preferred provider, substance abuse treatment is subject to available limits and pre-authorisation is required. Please call the Contact Centre on 0860 002 101 to obtain the necessary authorisation.

EXTERNAL SURGICAL APPLIANCES
Please phone the Scheme’s Contact Centre on 0860 002 101 to obtain pre-authorisation.

ONCOLOGY (CANCER) TREATMENT MANAGEMENT
In the event of you being diagnosed with cancer, your treating specialist must notify the Scheme before you receive treatment. This is to ensure that you receive the 100% benefit cover at the preferred rate on the cost of chemotherapy drugs that has been negotiated by the Scheme.

In addition, once you have completed your active oncology treatment, the Scheme will continue to pay for on-going consultations, pathology tests etc. from your Oncology Benefit, provided that the Scheme has received the necessary details from the Oncologist as part of your treatment plan.

Applications for chemotherapy are assessed on an individual basis, in accordance with recognised treatment protocols. Also note that all drug therapies used for the side effects of chemotherapy and pain relief are preauthorised by the ChroniCare Network.

To ensure that members get optimal treatment, the Scheme’s oncology benefit programme constantly monitors new and innovative drugs to treat cancer.

RENAL MANAGEMENT
Please ask your treating specialist to obtain pre-authorisation for renal dialysis from our Medical Advisory Committee (MAC) in writing. Once the application has been assessed and authorised by the MAC, authorisation is given for dialysis treatment.

Authorisation is also required for renal transplant applications. The Scheme's
pre-authorisation system ensures that correct renal treatment protocols are adhered to.

PRESCRIBED MINIMUM BENEFITS (PMBs)
With the new Medical Schemes Act requiring Schemes to pay for around 270 in-hospital and 21 chronic conditions Alliance Midmed has to settle related accounts for these conditions.

For the chronic conditions, schemes have to pay in full for the in and out-of-hospital diagnosis, treatment and care. The costs of which are to be paid according to published treatment guidelines. A list of benefits is available from the Contact Centre.

To obtain benefit for these services please phone the scheme for pre-authorisation for the treatment and ask your service provider to submit claims with the relevant ICD10 codes.

This will ensure that your benefits are paid from the correct category limits.

EX-GRATIA BENEFITS
The Scheme rules provide for additional benefits to be made available to members in exceptional circumstances. Given that these benefits are in addition to the normal benefits available, it is awarded at the discretion of the Board of Trustees. Allocation of the benefits are determined in the Scheme’s ex-gratia policy. Should members require ex-gratia benefits, application forms are available from the On-Site Scheme Consultant.

Completed applications must be submitted in a sealed envelope, marked:
Confidential-Ex Gratia Application
Att: Ex-Gratia Committee C/O Scheme Consultant
Alliance Midmed on-site Office
D-Block, Columbus Stainless,
PO Box 133,
Middelburg,
1050

OPTIMISING BENEFITS
To make the most of managing your day-to-day-expenses:
• Use doctors, dentists and other suppliers of service that charge NHRPL (National Health Reference Price List) rates.
• Consider seeing your pharmacist for minor ailments instead of a consultation with your doctor.
• When you consult with service providers that charge above- tariff rates, negotiate to settle the account earlier in return for discounts.

YOUR GUIDE TO PROBLEM-FREE ADMINISTRATION
Knowing where your claims refund is, or knowing what you are allowed to claim for, will eliminate many queries. Answers to your everyday administration queries can be found in the details of your benefit structure, included in this brochure. Equally important is that you know how the Momentum Medical Scheme Administrator "claims chain" works. In this section we will clarify the administration detail.

1. How to submit claims
Please mail or deliver your claims to Momentum Medical Scheme Administrators, PO Box 2338, Durban, 4000. Do NOT submit statements: only claims will be processed and paid.

If you have already paid a claim that the Scheme should refund you for, attach the receipt (ensure that your membership number appears on the account) and mark the claim as “paid”.

Please do not submit claims marked "FOR YOUR INFORMATION ONLY", or claims showing only a balance brought forward. These are for your records and should be used to check that payment was made. The Medical Schemes Act requires that service providers submit full details on all claims.

 

Claiming procedure
Please ensure that the following information is reflected on all of your accounts being submitted to the Scheme for payment. Your claims could be rejected if this information is ommited.
• Member number.
• Surname and initials of the principal member.
• Name and date of birth of the dependant who received the treatment
(this must be exactly as it is on your member card).
• Date of treatment.
• Valid doctors practice number.
• Tariff code.
• Cost of service.
• ICD 10 code.

There has been much communication from Alliance Midmed regarding ICD 10 codes. Please ensure that all applicable claims reflect these codes. The Scheme took a decision in 2006 NOT to pay claims where there are no ICD 10 codes. Providers and members have been briefed of this. If you are experiencing difficulties in obtaining the ICD10 codes for your claims from your providers, kindly contact Momentum Medical Scheme Administrators on 0860 002 101 for further assistance.

In respect of medication claims the following information is required in addition to the above information:
• Name of medication.
• Quantity / Dosage.
• Nappi code.
• Referring practice number.

Dental Treatment
Dental treatment often requires additional work by a dental technician. He/ she charge the dentist who then adds the amount to your claim and attaches a copy of the technician's claim. Please submit both claims and ensure that your name and membership number are reflected on each claim. Please ensure that you have copies of your claims.

When to expect payment?
Momentum Medical Scheme Administrators has more than two payment runs per month, to providers and members. If you have paid cash at the point of service, or your service provider charges above tariff you will receive the payment directly. If your service provider charges at NHRPL or at the Alliance Midmed rate, and you have not paid at the point of service, the payment will be made to the service provider. All valid claims received by Momentum Medical Scheme Administrators will be processed on this basis. Given the increasing amount of fraud, the Scheme no longer refunds payments by cheque. If you are expecting refunds, please provide Momentum Medical Scheme Administrators with your bank account details for electronic payment of refunds.

How will I know what was paid?
Momentum Medical Scheme Administrators sends a statement to you at the end of each month. You may also access the Alliance Midmed website and view your statement electronically. We have also introduced an sms facility that notifies members of all refunds into their accounts.

Referral Process
When you are referred to a specialist, please ensure that you know what rates the specialist charge before you consult him/her. It should include the specialist and all the services that relate to the specialist's treatment. Specifically note the fee charged by anaesthetists and all prescribed medicines and/or hospitalisation. Charges in excess of tariff rates will be for your own account. The Scheme recommends that you visit your GP and jointly decide when to consult with a specialist. When you visit a specialist, it is important that your GP gets a report back from the specialist. This will help your GP to take charge of your health and that your treatment, and specifically medication, is optimised.

Claims against the Road Accident Fund
If you are involved in a car accident and you have a possible claim against the Road Accident Fund, please note that you are required to furnish the Scheme with an undertaking to reimburse the Scheme for all claims paid for by the Scheme and recovered by you.

Claims against the Compensation Fund
When involved in a workplace injury, the Workmen’s Compensation Fund should pay for the related costs. To ensure that your medical scheme benefits are not exhausted if you are injured at work, contact your Human Resources or Safety Officer to assist with this process.

Overseas Travel Benefit
Please note that Alliance Midmed is a Scheme registered in the RSA. We will refund members in South Africa for costs incurred outside of South Africa’s borders, in South African Rands, upon receipt of a valid and legible invoice and proof that the member has settled the account. We will refund the costs, in terms of the Scheme rules, for which an insurance carrier has declined responsibility in writing.

Fraud and Abuse
Fraud has become a major issue in the medical Schemes industry with Schemes losing millions of Rands due to fraud and abuse. The greater the loss incurred through fraud, the higher your contributions become to help cover this loss. Alliance Midmed has measures in place to detect and manage fraud and abuse of benefits. Any Alliance Midmed member who is aware of a practitioner or member abusing the system can report it anonymously to the Fraud Hotline on 0800 11 2811.
This is a free service offered by the Scheme.

Important:
If you are unsure of the benefits offered by Alliance Midmed or if you sustain injuries as a result of an accident, an assault or an injury on duty, please contact us on 0860 00 21 01 to discuss what you should do.

 

If you wish to gain access for the first time you need to go to www.alliancemidmed.co.za and complete the application for on-line access. Fax the form back to Momentum Medical Scheme Administrators on the fax number provided. An e-mail will then be sent to you with your password and username. Once you have your username and password, access the website and click on Alliance Midmed and enter the username and password to view your information.

EXCLUSIONS
There are a number of treatments and medicines that the Scheme will not pay for. Listed below are some of the exclusions applied by your Scheme:
• all costs for operations, medicines, treatments and procedures for cosmetic purposes or for personal reasons and not directly caused by or related to illness, accident or disease;
• all costs for treatment, if the efficacy and safety of such treatment can not be provided;
• injuries or conditions wilfully self-inflicted or injuries sustained while voluntarily participating in a riot, civil war commotion, war, invasion, act of foreign enemy, hostilities whether war is declared or not;
• injuries arising from professional sport, speed contests and speed trials or any other recreational activity which the Scheme considers as being inherently dangerous;
• accommodation and services provided in a geriatric hospital, old age home;
• anabolic steroids, immuno-stimulants, growth hormones;
• appointments which the beneficiary fails to keep;
• autopsies;
• tubal legation and vasectomy;
• cosmetic preparations, emollients, moisturisers, medicated or otherwise, soaps, scrubs and other cleansers, sun- screening and sun-tanning preparations, medicated shampoos and conditioners;
• medicines used specifically to treat infertility unless treatment is a PMB;
• medicines not approved by the Medicine’s Control Council;
• telephone consultations;
• minerals and tonics other than iron and folic acid.

For further information on exclusions please call the Scheme on 0860 002 101.

 

100% OF TARIFF: A charge that is equal to 100% of the rate that the scheme decides to pay for services.

ACUTE MEDICINES: Medicines used for short term illness and medical problems, also called day-to-day medication. Medicine prescribed for a temporary / short term illness or condition and cannot be obtained without a doctors' prescription.

ANGIOGRAMS: An x-ray of blood vessels; the person receives an injection of dye to outline the vessels on the x-ray.

ALLIANCE MIDMED RATE / TARIFF: A rate that is higher than the NHRPL, applicable to a range of services, including Specialists and General Practitioners. Please contact the Alliance Midmed Call Centre on 0860 002 101 for more information.

BENEFICIARY: A beneficiary is either the Principal Member or one of his / her registered dependants. Also see dependent.

BENEFIT LIMIT: The maximum amount of a specific benefit that you are covered for in a benefit year (calendar year). Benefits will be allocated on a pro-rata basis if you join the scheme after January (e.g. if you start in May, you will receive 7/12ths (or 58.33%) of the benefit allocation).

CHILD DEPENDANT: See dependent.

CHRONIC DISEASE LIST (CDL): A list of chronic illnesses for which Alliance Midmed Medical Scheme pays from the Major Medical Pool (chronic medicine benefit). The Council for Medical Schemes legislate a list of 27 specific chronic conditions for which a minimum level of treatment is compulsory.

CHRONIC MEDICATION BENEFIT ENTRY CRITERIA: In most instances the Scheme requires specific diagnostic tests/ examinations/ reports to confirm a chronic illness, e.g., blood tests or ECG reports, etc. Please call the Scheme on 0860 002 101 for specific information.

CHRONIC MEDICINES: Medicines used to manage conditions as listed in the Scheme's chronic disease list, available from the Call Centre on 0860 002 101. These medicines are prescribed by a medical practitioner for an uninterrupted period of at least three months (e.g. for heart conditions, high blood pressure, etc.). Note that the Scheme's chronic diseases list is not the same as the gazetted CDL in that Alliance Midmed covers many more conditions. Note that for some medicines payment will only be made if it is prescribed by a specialist.

CONSULTATION: A visit to your doctor, surgeon or other service provider to get a diagnosis and/or treatment for your specific condition.

COMPUTERISED AXIAL TOMOGRAPHY: Cat Scans. See CT and MRI Scans.

DAY-TO-DAY BENEFITS: Benefits obtained outside of hospital and include some of the visits to your doctor, acute medication, dentistry and optical benefits and are defined as such in your member handbook.

DENTAL CARE:
Dental Benefit Management Programme: An administrator- managed programme that is specifically designed to manage the dental costs and monitor the quality of work done by dentists attending to Alliance Midmed members.

Lingual Orthodontics: This form of therapy requires the placement of bands and or braces on the inside of a person's teeth, generally for cosmetic reasons.

Malocclusion: The incorrect alignment of the upper and lower teeth. This is very common and does not necessarily need to be treated.

Maxillo-facial surgery: The treatment of all traumas to the bone and soft tissue of the face; or the surgical removal of teeth that require cutting into a persons jaw bone.

Specialised dentistry: Advanced dental work that involves the fitting of caps, crowns and bridges. This typically requires the services of a dental technician and dental laboratory to prepare the necessary material to be used by the dentist. Specialised dentistry on Alliance Midmed does carry a 25% co-payment except for the fitting of crowns which have NO co-payment

DESIGNATED SERVICE PROVIDER (DSP): Medical Schemes sometimes enters into special agreements with doctors or doctor groups and in some cases hospitals to provide discounted rates and/or guaranteed access to their facilities for members of that scheme.

ELECTRO-CONVULSIVE THERAPY (ECT): Also known as "shock therapy". This is done by causing a brief seizure through an electric current sent through the brain for the treatment of nervous disorders.

GENERAL PRACTITIONER (GP): A doctor whose practice consists of providing general or ongoing care covering a variety of medical problems in patients of all ages. The GP may refer patients with complex or very serious diseases or illnesses to appropriate specialists. The GP is also called "family doctor."

GYNAECOLOGIST: A doctor that specialises in the treatment of diseases in and around the female reproductive organs. Gynaecologists also treat pregnancy and are tasked with the duty of delivery during childbirth.

HEALTH PROFESSIONS COUNCIL OF SOUTH AFRICA (HPCSA): The HPCSA is the regulatory and registration body of the Medical, Dental and other health professionals. Registration for practicing health professionals is compulsory (including traditional healers, when the new law that will be passed soon comes into effect).

HIV/AIDS:
Acquired Immune Deficiency Syndrome (AIDS): AIDS is a collection of symptoms and infections resulting from the contraction of the Human Immuno virus from one person to another. If not properly treated, AIDS may result in a persons' immune system weakening to such an extent, that the person may die of common illnesses such as pneumonia or influenza.

Antiretroviral therapy / treatment (ART): These are medicines used to treat HIV. ART's maintain critical levels of white blood cells that protect the body against damage caused by HIV to the immune system. ART's do not get rid of HIV.

Human Immune Deficiency Virus (HIV): This is the virus that enters the blood stream and causes AIDS. This virus is passed from one person to another through blood-to-blood and sexual contact. In addition, an infected pregnant woman can pass HIV to her baby during pregnancy or delivery, as well as through breast-feeding. People with HIV have what is called HIV infection. Eventually HIV infected individuals will develop AIDS as a result of their HIV infection.

Voluntary Counselling and Testing (VCT): In order to establish whether a person has HIV, they may request to be tested voluntarily and if so they may require counselling depending on their status. This is a confidential process and it is in most instances a free service.

HOMEOPATHY: Treatment based on the use of small doses of medicine to introduce a particular disease into the body so that a person's body develops a resistance to that disease naturally. Homeopathy also uses natural or herbal products to treat diseases.

LAPAROSCOPIC SURGERY: A laparoscopy is a type of surgical procedure in which a small incision is made, usually in the navel, through which a viewing tube (laparoscope) is inserted. The viewing tube has a small camera on the eyepiece. This allows the doctor to examine the abdominal and pelvic organs on a video monitor connected to the tube.

MAJOR MEDICAL EXPENSE: These are high cost events and/ or items such as hospitalisation and chronic medication.

MANAGED CARE: Managed Care Programmes aim to manage healthcare costs and access by promoting appropriate and cost-effective utilisation of services at an affordable price and encourages the participation of the patient's doctor to better manager that patient's health.

MEDICINES:
Medicine Exclusion List (MEL): An exclusion list specific to the Scheme that excludes payment for certain medicines for various reasons.

Medicine Formulary: A medicine formulary is a list of cost- effective medicines that guides the doctor in the treatment of specific medical conditions. Medicine formularies are continuously checked and updated by medical experts to ensure that they are consistent with the latest treatment guidelines. Alliance Midmed does not use a formulary, but rather regulate medicine prices through the MMAP (see elsewhere in this document).


Maximum Medicine Aid Price (MMAP): Maximum Medical Aid Price is the maximum price the Scheme will pay for the cost of generic medicine. If no generic is available, the Scheme will cover the cost of the prescribed branded medicine. Should you and/ or your doctor elect to purchase the branded product in lieu of the generic, only MMAP for the generic will be paid by the Scheme and you will liable for the difference.

Pharmacy Advised Medicines (PAT): This benefit is payable from the members' medical savings account. PAT medication is schedule 1 and 2 medicine that is recommended by your pharmacist, without a doctor's script. It is also known as "self medication" or "over the counter medicine".

Professional Dispensing Fee (PDF): A legislated maximum fee that a pharmacist or ispensing doctor may charge for services rendered.

NATIONAL HEALTH REFERENCE PRICE LIST (NHRPL): The benchmark tariff published by the Council for Medical Schemes.

OUTPATIENT DEPARTMENT: This is the Emergency Room (ER) of a hospital where patients treated and then sent home without being admitted into the hospital itself. Note that Alliance Midmed deducts an amount off your hospital bill if you made use of ER services for reasons other than an emergency.

PATHOLOGY: The study of diseases with the aim of understanding their nature and cause. This is achieved by observing, blood, urine and faeces samples from the patient.

PHYSIOTHERAPY: The physical treatment of disease, injury or deformity using methods such as heat, massage and exercise.

PMSA: Personal Medical Savings Account: The scheme allocates a portion of your monthly contribution to a savings account held in your name. The money in this account is used to pay for your day-to-day medical expenses. When the money in your account runs out, you run out of day-to-day benefits.

PRE-AUTHORISATION: The confirmation received from the Scheme when a member requires hospitalisation, a specialised procedure or specialised radiology. The Scheme will then be able to monitor the quality of care that you will receive. Pre-authorisation does not guarantee payment of claims but is merely a pre-notification mechanism whereby the Scheme is advised of a pending procedure/treatment and provides confirmation that the member may have access to benefits.

PRESCRIBED MINIMUM BENEFIT (PMB): All medical schemes must pay for, as a minimum, a specified list of minimum benefits for its members and their dependants. PMB's also include the in and out-of-hospital care for 27 chronic conditions. Please obtain pre-authorisation.

PREVENTATIVE TREATMENT: Treatments that will stop a condition from developing or getting worse. For example, going to your dentist to have your teeth checked and cleaned regularly helps to stop you from getting more serious problems (like tooth decay or infected gums) that would be more costly and difficult to fix at a later stage.

PRO-RATED BENEFITS: Schemes, including Alliance Midmed Medical Scheme, provide cover for a calendar year - that is January to December. Should you join the scheme in July, you would have access to only half of the benefit values for the six months from July to December, because you are only contributing to the scheme for six months instead of twelve months. These are called pro-rated benefits. For example, if you are allowed R1,000.00 for doctor's visits, the pro-rated benefit will be R500.00.

PROSTHESIS: An artificial replacement for a body part, such as a leg, arm or breast (non-surgical) and items such as hip or shoulder replacements (surgical) which will be performed by an orthopaedic surgeon.

REHABILITATION: Treatment to help you get back to a normal life following injury or disease. Rehabilitation treatment is provided at step down facilities or by registered nurses, physiotherapists or chiropractors.

SADA: The South African Dental Association is a professional association for dental practitioners. The SADA rates as set by this Association are also referred to as private fees or "contracted out" fees. This tariff is higher than the NHRPL tariff. Membership of this association is not compulsory.

SAMA: The South African Medical Association is a professional association for medical practitioners. The SAMA rates as set by this Association are also referred to as private rates or "contracted out fees". This tariff is higher than the NHRPL tariff. Membership of this body is not compulsory for medical practitioners.

SAVINGS OPTION: See Personal Medical Savings Account.

SCHEME RATE: The Alliance Midmed Rate/ Tariff.

SINGLE EXIT PRICE (SEP): This is a legislated price charged for medication by a pharmacist or dispensing doctor.

SPECIALISTS: Doctors who have specialised in a particular medical field, such as oncology, paediatrics, gynaecology, etc.

SUB-ACUTE FACILITY: Also known as a step-down facility or a nurse-based unit. It is similar to a hospital but without all of the specialised areas such as theatres, Intensive Care Units, High Care Units, X-ray departments, casualty units, pharmacies, laboratories etc. The ratio of nursing staff to patients is also relatively lower than a fully fledged hospital ward which means that sub-acute facilities should cost much less than a hospital to run.

TREATMENT PROTOCOLS: Rules and processes that are followed for treating a specific condition. These protocols are usually decided in consultation with an authorative body of that particular condition, e.g. Oncology protocols will be discussed with the South African Oncology Association, etceteras.

TO-TAKE-OUT MEDICINE: This is medication prescribed by your doctor, for use at home once you have been discharged from hospital and normally consists of a seven day supply of the relevant medicines.

X-RAYS: An image of parts of the body (usually bones) produced on photographic film.

WAITING PERIOD: Some medical schemes restrict members from claiming for any benefits (except PMB's) within the first three months of the member joining that scheme. This is usually done when members have no previous medical scheme cover or have had a break in medical aid cover.