Terminology

Don’t let industry-speak put you off making the best decision for your health.

Abbreviations uncovered

AT  Agreed Tariff

CDL Chronic Disease List

DSP Designated Service Provider

TRP Topmed Reference Price (generic & therapeutic substitution)

PAR Pre-authorisation reference number

PAT Pharmacy Advised Therapy

PMB Prescribed Minimum Benefit

TRP Topmed Reference Price

TT Topmed Tariff is the rate that is applicable for the payment of benefits, including the National Health Reference Price List Rate or amended rate as published by Topmed or its agent from time to time

TTO To Take Out

 

A
Act: The Medical Schemes Act, 1998, as amended or replaced from time to time, and the regulations promulgated thereunder

Acute Medicine: Medicine used for diseases or conditions that have a rapid onset, severe symptoms, and that require a short course of medicine treatment, as well as medicines that qualify for benefits but have not been classified as chronic medicine by Topmed.

Adult: A dependant who is 21 years or older.

Agreed Tariff: Where agreements have been entered into with preferred providers, the tariff as specified in the agreements, as amended from time to time, and/or for medicine the single exit price plus the negotiated dispensing fee subject to MMAP.

Annual Threshold: A threshold is a set value to be reached before claims for day-to-day medical expenses are covered from Major Medical. All day-to-day claims paid from the member’s Yearly Limit / MSA or self-funded, accumulate towards reaching this threshold. Once this threshold limit is reached, further day-to-day claims will be paid by Topmed subject to benefit limits as stipulated in the benefit summary for each option.

Application Date: The date on which the application for membership of Topmed, or registration of a dependant, is actually received by Topmed.

 

B

Beneficiary: Each individual member and dependant.

 

C

Case Management Programme: A process whereby clinically indicated, appropriate and cost-effective healthcare, as an alternative to hospitalisation, or otherwise, is offered to beneficiaries with specific healthcare needs – whether Topmed prescribes it or approves it on application by a beneficiary.

Chemotherapy: Medication used in the cure and containment of cancer. This includes cytostatics and hormone inhibitors and excludes medication for the side effects of chemotherapy

Chronic Medicine:

Medicine that meets all the following requirements:

  • prescribed by a medical practitioner for an uninterrupted period of at least three months; and
  • for a condition appearing on Topmed’s list of approved chronic conditions as amended from time to time; and
  • which has been applied for in the manner and at the frequency prescribed by Topmed from time to time, and which application has been accepted by Topmed.

Clinical Procedure: A procedure categorised as such by the Board of Healthcare Funders.

 

D

Dental Implants: Placement of metal rods into the jaw bone in the place of a missing tooth to provide a structure upon which a crown or denture can be placed.

Dependant: The following persons for whom the member is liable for family care and support, and who are not members or dependants of members of any other medical scheme and, if applicable, who are duly registered as dependants by Topmed:

  • a spouse/partner; and/or
  • a child – including an adopted child, stepchild or foster child; and/or
  • the principal member’s parents, sisters and brothers; and/or
  • any other person approved by Topmed.

Designated Service Provider (DSP): Topmed’s chosen service provider used to offer benefits in respect of the Prescribed Minimum Benefit conditions.

Disease Management: A holistic approach focusing on the patient, using all the cost elements of the disease to identify the patient eligible for a disease management programme. The intervention takes place by means of:

  • Patient counselling and education
  • Behaviour modification
  • Therapeutic guidelines (the application of)
  • Incentives and penalties; and
  • Case management.
E

Effective Date: The date on which a beneficiary becomes entitled to benefits.

Extended Cover / Above Threshold Benenfit: Cover provided by the Scheme for day-to-day claims once the Yearly Limit / MSA is depleted, and a set Threshold value is reached. Once this threshold limit is reached, further day-to-day claims will be paid by Topmed subject to benefit limits as stipulated in the Rules.

Emergency: Emergency – a condition manifesting itself by acute symptoms of sufficient severity (including severe pain), where of the absence of immediate care could reasonably be expected to result in:

  • placing the health of a beneficiary or unborn child in serious jeopardy
  • serious impairment of bodily functions
  • serious dysfunction of any bodily organ, limb or system
F

Family: A member and his/her dependants.

Formulary: A defined list of medicine used in the treatment of various diseases.

 

H

Hospital: Includes a mental health institution, registered unattached theatre and day clinic, but excludes an institution for rehabilitation for substance abuse.

 

I

Inception Date: The date on which a person becomes a member of Topmed or on which a dependant’s registration becomes effective.

 

L

Late Joiner: An applicant or the adult dependant of an applicant who, on the Application Date, is 35 years or older but excludes any beneficiary who enjoyed coverage with one or more medical schemes as from a date preceding 1 April 2001, without a break in coverage exceeding three consecutive months since 1 April 2001.

 

M

Major Medical Benefits: Insured benefits for services such as hospitalisation and the treatment/procedures performed whilst a beneficiary is hospitalised.

Maxillo-Facial Surgery: The treatment of cysts and tumours of the jaw, as well as conditions of the saliva glands; the treatment of abscesses of the jaw, excluding periodontal therapy; and/or the treatment of all traumas to the bone and soft tissue of the face; or the surgical removal of teeth.

Medical Savings Account: A savings facility to which members contribute monthly. A credit equal to 12x the monthly savings contribution is available upfront to be utilised in respect of almost any medical services or supplies; even some of those that are otherwise excluded from benefits on the Active Saver, Savings, Family and Executive options.

Medicine: A substance registered under the Medicines and Related Substances Control Act of 1965, as amended or replaced from time to time.

Member: A person who has been registered as a member by Topmed.

Minor: A dependant who is not yet 21 years old.

 

N

NRPL List (National Reference Price List): The tariff and applicable rules for specific services or supplies provided, based on the 2006 NRP List published by the Council for Medical Schemes, with annual inflationary increases.

 

O

Orthodontics: Braces and removable plates which realign the teeth within the jaw bone.

 

P

Periodontal Surgery: Advanced treatment of gum infection which includes deep cleaning of roots with the gum flapped open and grafting of oral tissue.

Pre-Authorisation Reference Number (PAR): A number allocated by Topmed’s managed healthcare agent, which is required before certain services qualify for benefits.

Preferred Provider: A service provider with whom preferential rates were negotiated by or on behalf of Topmed, or who is part of a preferred provider network contracted for or on behalf of Topmed.

Prescribed Minimum Benefits: The minimum benefits that Topmed is obliged to provide under the Act.

 

R

Registrar: The Registrar of Medical Schemes appointed in terms of the Medical Schemes Act.

 

S

Self-Payment Gap: A period during which a member will be required to fund a certain portion of day-to-day claims from his/her own pocket after the Yearly Limit/Medical Savings Account is depleted.

Service Date: In the event of:

  • hospitalisation – the date of each discharge from a hospital; or termination of membership, whichever takes place first
  • any other service or supplies – the date on which the service was rendered or the supplies obtained, whether for the same illness or not.

Service Provider: A medical practitioner, dentist, pharmacist, nurse, medical auxiliary or hospital duly registered or licensed as such with a statutory council or relevant state department – or if practising in a territory outside South Africa, registered or licensed as such with a similar body in that territory.

 

T

Topmed Reference Price (TRP): The maximum price that Topmed is prepared to pay for a medicine with generic alternatives. TRP sets a reference price for a list of generically similar products at which these products are reimbursed.

Topmed Tariff: The rate that is applicable for the payment of benefits, including the NRPL Rate or amended rate as published by Topmed or its agent from time to time.

Threshold: A specified amount, calculated according to family size, to which certain day-to-day claims accumulate when paid from your Medical Savings Account, Yearly Limit or from your own pocket. Once the threshold amount is reached, Topmed will start paying further day-to-day claims according to option specific Protocols and Rules.

Trauma: An acute episode where emergency or trauma has occurred and life-saving treatment is provided until such time as the patient’s critical condition has been stabilised. It does not include ongoing medium to long term rehabilitation, chronic medication and treatment of disabilities unless they form part of the Chronic Disease List conditions.

 

Y

Year: A period of 12 months beginning on 1 January and ending on 31 December.

Yearly Limit: The annual allowance allocated per member for payment of day-to-day benefits until an annual threshold level is reached