SchemeBook · Plain language
Jargon, explained
The words a medical scheme's rules use, in plain language — for anyone who needs to read them.
Term
Open scheme
Anyone can join, regardless of employer.
TermRestricted scheme
Membership is limited to a specific employer, industry, or profession.
TermPMB (Prescribed Minimum Benefits)
A legally mandated minimum level of cover every scheme must provide.
TermCDL (Chronic Disease List)
The specific chronic conditions PMB cover extends to.
TermDTP (Diagnosis Treatment Pair)
The government-set minimum treatment standard for a CDL condition.
TermCo-payment
An amount you pay yourself, on top of what the scheme pays.
TermDesignated Service Provider (DSP)
The provider your scheme names as the no-extra-cost option.
TermWaiting period
A window after joining where some or all benefits aren't payable yet.
TermLate-joiner penalty
A permanent extra premium loading for joining a scheme later in life.
TermSavings account / above-threshold benefit
A day-to-day medical spending pot that isn't the same as your main cover.
TermMedical scheme
A regulated, member-funded pool that pays healthcare benefits under registered rules.
TermMedical aid
The everyday South African name commonly used for medical scheme cover.
TermMedical insurance
An insurance policy that pays stated amounts for specified health events.
TermBenefit option
The specific plan selected inside a medical scheme.
TermPrincipal member
The person in whose name the membership is registered.
TermDependant
An eligible person covered under the principal membership.
TermContribution
The regular amount paid to keep membership active.
TermUnderwriting
The limited membership conditions a scheme may assess when someone joins.
TermCondition-specific waiting period
A temporary restriction on claims linked to a pre-existing condition.
TermEmergency medical condition
A sudden condition needing immediate care to prevent serious harm.
TermMedical savings account
Part of a contribution set aside for eligible day-to-day claims.
TermSelf-payment gap
A period when savings are finished and the member funds day-to-day costs.
TermBenefit limit
The most an option will pay for a defined benefit in a period.
TermScheme tariff or rate
The price level an option uses to calculate payment.
TermOut-of-pocket payment
Any healthcare cost paid by the member and not reimbursed.
TermProvider network
A group of healthcare providers contracted for an option or benefit.
TermFormulary
The list of medicines a scheme approves for a benefit.
TermGeneric medicine
A medicine with the same active ingredient as an original brand product.
TermClinical protocol
The evidence-based steps used to decide how a condition should be treated.
TermPre-authorisation
Approval requested before planned treatment or admission.
TermManaged care
Programmes that coordinate treatment and apply clinical funding rules.
TermClaim statement
The scheme's record of how it processed a claim.
TermTariff shortfall
The difference between the provider's charge and the scheme payment.
TermClaim rejection
A decision not to pay all or part of a claim.
TermClinical motivation
Information from a clinician explaining why care is medically necessary.
TermInternal appeal
A request for the scheme to reconsider its own decision.
TermCMS complaint
A formal complaint to the Council for Medical Schemes.
TermRegistered scheme rules
The legally registered terms governing membership and benefits.