CAMAF Member Option Guides & Info

LINKS Benefits Brochure Scheme Rules Member Login GET IN TOUCH T 0860 100 545 / 011 707 8400 E custcare@camaf.co.za Why some claims aren't paid. We understand that receiving the news that your medical aid won't cover certain expenses can be frustrating and confusing. It's a situation many of us have encountered, sparking discussions among friends and family. To shed light on why these situations arise, let's dispel some common misconceptions and replace them with accurate information. Firstly, it's crucial to grasp how a medical aid operates. Unlike insurance, a medical aid is not driven by profit and covers claims and administration costs through member contributions. At CAMAF, where administration costs are kept below 8% of contributions (as we are self-administered), contribution increases directly correspond to the claims submitted by covered lives. It is, therefore, important to note that containment of claims paid by the medical aid is as important as expenses paid in your personal capacity. As the pool of funds available is limited to the contributions received, strict application of Scheme Rules is imperative to protect members' best interests. Unlike insurers, a medical scheme may not charge different contributions based on age, health status or healthy behaviours. Discounts on contributions for groups may also not be offered. It, therefore, relies on the principles of cross-subsidisation between healthy and ill and based on income (on income band-based options). Your medical aid consists of a risk pool and, if an applicable option is chosen, a medical savings account (MSA). The risk pool is collective and available to all members, while the MSA is individual and refundable upon leaving or changing to options without an MSA. Understanding these structures is vital to navigating the complexities of a medical aid. Now, let's explore some common reasons: 1. Provider administration errors: Mistakes on submitted claims, like incomplete information, illegible information, or coding errors, can result in rejections. 2. Option selection: Cheaper options may have more restrictions to keep contributions low, such as lower benefit limits, more restricted medicine lists, network constraints, and lower tariff reimbursement rates. 3. Treatment plans: Treatments outside of clinical best practice standards, including overservicing, clinically inappropriate treatments or experimental treatments, may not be covered. 4. Provider rates: Providers charging above the medical aid's base rate may lead to co-payments. Members are best placed to negotiate with their healthcare provider to limit co-payments if the provider is not part of the CAMAF network. 5. Benefit limits: Out-of-hospital limits exist to control contributions, and claims will be rejected once these limits are reached. 6. Lack of pre-authorisation: Some benefits, including non-emergency in-hospital treatments, require pre-authorisation. This is to assist in confirming CAMAF benefits and to provide the clinical team with insight into the appropriateness of care in alignment with clinical best practice. 7. Unregistered chronic conditions: Failure to register a chronic condition as per your chosen option may result in unpaid medication claims. 8. Chronic disease list: The chronic diseases covered differ per option. Chronic conditions not listed on these disease lists won't be covered as a medical aid has a limited pool of funds and, therefore, must carefully consider which diseases to include. 9. Early medication refill: Strict refill timelines exist to prevent overdosing or stockpiling. Extended supplies may be requested from the clinical department when travelling. 10. Non-adherence to disease management protocols: Regular checkups, script renewals, and required tests are essential for optimal chronic condition management and continued payment of claims. A letter stipulating these requirements is sent upon application to register your chronic condition. 11. Non-network providers on Network Options: Using non-designated network providers on network options may incur co-payments. 12. Exclusions: All medical aids have a list of exclusions to protect the fund. Refer to the Scheme Rules for specific details. 13. Scheme processing errors: Human errors are kept to a minimum at CAMAF through rigorous testing and automation, and although this is not one of the top reasons, we need to note that it could occur. Please refer to the Scheme Rules on our website or the benefits brochure. Note that the brochure does not supersede the Scheme Rules and is only a summary for ease of reference. It's important to note that medical aids may cover treatments differently based on their focus and benefit structures. Some medical aids or options pay claims from your individual pool of MSA. CAMAF has a strong focus on covering claims when you need it most, for example, but not limited to hospitalisation and oncology cover. Creating healthy behaviours through the utilisation of preventative benefits and programmes helps reduce claims and, ultimately, contribution increases. As members, along with the board, executives, and employees, we share a collective responsibility to safeguard CAMAF's funds and uphold the medical aid's rules, protocols, and ethical standards. This joint effort aims to eliminate fraud, waste, and abuse, protecting the best interests of all members. Healthcare provider: Your medical aid won't pay.

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