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How do medical schemes work?
The first important point to note is that the medical scheme belongs to you, the member.
All medical schemes in South Africa are non-profit organisations, governed by the Medical Schemes Act and regulated by the Council for Medical Schemes. The monthly contributions members pay to the scheme are pooled and used to pay for members’ healthcare expenses, in line with the scheme’s rules and the benefit option chosen.
What do medical schemes do with the contributions they receive from members?
Medical schemes contract with an administrator to handle all administrative processes on their behalf. These include the collection of contributions, the processing and payment of claims, the handling of any queries and member correspondence, etc. It can also include the marketing of the scheme. In turn the administrator receives a monthly fee from the scheme which gets disclosed to both the Council for Medical Schemes (the regulatory body that governs all South African schemes) as well as annually to members of the medical scheme. The administrator needs to ensure that the services contracted are performed in line with the Board of Trustees’ expectations.
Acquisition, marketing and distribution
The marketing and promotion of the scheme can be outsourced to the administrator, including paying financial advisers to help grow the scheme with new members. Commission is tightly regulated and may not exceed 3%, up to a maximum of R94.77 per month, per membership.
Medical schemes receive their income purely from members’ contributions. This money needs to pay for all the claims they have to settle (known as healthcare costs) as well as all the contracted costs explained above (non-healthcare costs). Another important point to note is that schemes are not allowed to charge members different contributions based on their age, gender, health status or any other discriminatory factor. They may also not refuse any person membership and can, at most, apply certain waiting periods to minimise their risk.
Momentum Medical Scheme is committed to ensuring that the interests of our members are protected at all times.
This includes providing appropriate and adequate systems and processes to make sure we settle your claims timeously and providing a prompt response to any queries, complaints and disputes you may have.
An aggrieved member does, however, have the right to lodge a complaint against a decision of Momentum Medical Scheme. Such complaint can be lodged with the Council for Medical Schemes (CMS). The CMS governs the medical schemes industry and therefore your complaint should be related to your medical aid. Any beneficiary who is aggrieved with the conduct of a medical scheme can submit a complaint. You can send your complaint in writing to the CMS via email at firstname.lastname@example.org or via fax on 012 431 0608. The CMS can also be reached telephonically on 0861 123 267 or you can visit medicalschemes.com for more information and for the necessary forms that will need to be completed.
Request Scheme Rules
On request, the Scheme Rules can be made available to members of the Scheme. You can submit a request by logging on to www.momentum.co.za