Frequently Asked Questions
Under the Medical Schemes Act 131 of 1998, medical schemes are registered as Section 21 companies and are therefore non-profit organisations. Bankmed's primary source of income is from contributions collected from its members. This income is then used to pay for healthcare claims submitted by members and providers of healthcare services.
Examples of healthcare claims that Bankmed pays on behalf of members:
- Hospitalisation
- Major medical expenses (e.g. cancer treatment)
- Medication (e.g. chronic medication, acute and other over-the-counter medication)
- Routine consultations with healthcare professionals
The expenses listed above constitute the Scheme's healthcare expenditure.
A small percentage of the contribution income is used to fund administration costs associated with the management of the Scheme. This includes the costs associated with financial management, running of Bankmed Customer Services and the provision of management services for disease, medication, hospital and clinical cases. These expenses are known as non-healthcare expenditure.
An operating surplus is generated if the Scheme's total expenditure is less than the total contributions collected for the benefit year. Conversely, an operating loss is incurred should the total expenditure exceed the total contributions collected.
Once an operating surplus is generated, the funds are transferred to the Scheme's pool of reserves. It is important to note that the Scheme's reserves belong to the members.
Regulation 29 (2) of the Medical Schemes Act states that a medical scheme must maintain accumulated funds (reserves) expressed as a percentage of gross annual contributions for the accounting period under review, which may not be less than 25%. Reserves have to be maintained above 25% to ensure the financial sustainability of the Scheme.
Important contact details for Bankmed are provided for you in your Benefit and Contribution Schedule. Click here for a list of contact details.
The following are examples of items typically not covered by Bankmed:
- Operations, treatment and procedures for cosmetic purposes
- Examinations, consultations and treatment related to obesity
- Sunscreens and tanning agents
- Travel expenses
- Accommodation in old age homes or similar institutions
- Sunglasses
- Accommodation and/or treatment in headache or stress-relief clinics
- The cost of holidays for recuperative purposes (for example spas and health resorts)
- Telephone consultations with medical practitioners
- Costs associated with vocational guidance, child guidance, marriage guidance or counselling, sex therapy, school readiness, school therapy or attendance at remedial education schools or clinics.
View the complete list of the Scheme exclusions in accordance with Bankmed's Rules.
No, Insured Benefits are not transferrable. However, positive (unused) balances in your Medical Savings Account (if you are on Core Saver, Comprehensive or Plus Plans) are carried over from one year to the next.
Yes, always obtain pre-authorisation where indicated as a requirement in the Benefit and Contribution Schedule. Please also see Questions about emergency services and pre-authorisation for more information on when and how to obtain pre-authorisation.
No, headache clinics are not covered by Bankmed and are specifically excluded from benefits.
Yes, homeopathic medicines may be claimed from your available medication benefits, but only if referred to by a doctor to treat a medical condition, meaning there must be a specific diagnosis. The medication must be registered with the Medicines Control Council and have a NAPPI code for claiming purposes. Bankmed does not cover homeopathic medication without a prescription - off-the shelf or over-the-counter homeopathic medication will therefore also not be covered.
The Annual Threshold must be reached before the Above Threshold Benefit (ATB) applies.
Accumulation of claims (paid from your Medical Savings Account) towards the Annual Threshold (AT):
- Relevant claims (paid from available funds in the Medical Savings Account and subject to the Above Threshold Benefit) accumulate towards the annual threshold at 100% of the Scheme Rate
- Any difference between the cost of an account and the Scheme Rate will not accumulate towards the Annual Threshold, although this difference may be covered from available funds in the Medical Savings Account
The Annual Threshold is set per family and is calculated as follows:
- R24 600 for the Principal Member + R18 300 per adult + R6 100 per child dependant (limited to three children)
- The total of the above sum is the Annual Threshold that must be reached before the Above Threshold Benefit applies
The Above Threshold Benefit acts as a safety net should you experience unusually high day-to-day (out-of-hospital, non-PMB) costs during the year. Relevant claims are paid at 100% of the Scheme Rate as an Insured Benefit from the Above Threshold Benefit after the Annual Threshold is reached.
The Above Threshold Benefit is set per family and is calculated as follows:
- R22 900 for the Principal Member + R17 200 per adult + R5 700 per child dependant (but limited to three children)
Read more about the Annual threshold and Above Threshold Benefit.
Your contributions are payable monthly in arrears. Your employer will collect your contribution from your month-end salary and pay it over to Bankmed (for that month). This means that your January contribution will be deducted by your employer from your January salary, your February contribution from your February salary and so forth.
Should you join Bankmed on or before the 15th day of a month, a full month's contribution will be due for that month.
If you join Bankmed after the 15th day of a month, (i.e. if your employment date falls after the 15th) you will not be liable for a contribution for that month. Your first contribution will be due at the end of the following month for that month, for example, if you join on 20 February, your first contribution will be deducted from your March salary, for March, but you will already be entitled to claim benefits from 20 February.
Please note that, although the payment of contributions may be facilitated by your employer, you ultimately remain responsible for the payment of any contributions owing to the Scheme.
Yes, benefits for chronic medication (subject to available benefits as indicated in the benefit schedule for your Plan) are only available to members who have applied for- and obtained the necessary pre-authorisation.
Benefits are not provided retrospectively. It is therefore important that you apply for chronic medication benefits as soon as your doctor diagnoses you with a chronic condition and provides you with a prescription for ongoing medication. Bankmed may require additional information from your doctor before authorising your chronic medication.
For Basic and Essential Plans:
Call us on 0800 BANKMED (0800 226 5633) or 011 539 7000
Alternatively, you can submit a completed Chronic Medication Application form via e-mail to ChronicBasicEssential@bankmed.co.za
For Comprehensive, Core Saver, Plus and Traditional Plans:
Call us on 0800 BANKMED (0800 226 5633) or 011 770 6247
Alternatively, you can submit a completed Chronic Medication Application form via e-mail to chronic@bankmed.co.za
If you do not qualify for chronic medication benefits (i.e. if the clinical and funding criteria applied by the Scheme for the payment of chronic medication benefits are not met), or if your chronic medication benefits are exhausted, you will still be able to claim benefits for medication from an alternative benefit category, e.g. from acute medication or from your Medical Savings Account (subject to available limits) or as Prescribed Minimum Benefit, if applicable.
Benefits are not provided retrospectively. It is therefore important that you apply for chronic medication benefits as soon as your doctor diagnoses you with a chronic condition and provides you with a prescription for ongoing medication. Bankmed may require additional information from your doctor before authorising your chronic medication.
If you do not qualify for chronic medication benefits (i.e. if the clinical and funding criteria applied by the Scheme for the payment of chronic medication benefits are not met), or if your chronic medication benefits are exhausted, you will still be able to claim benefits for medication from an alternative benefit category, e.g. from acute medication or from your Medical Savings Account (subject to available limits) or as Prescribed Minimum Benefit, if applicable.
A formulary is a comprehensive list of medication for the treatment of a number of conditions that your Plan covers. The formulary serves two purposes. One is to ensure that the medication offered are of the highest quality and efficacy. The other purpose is to reduce the cost of prescription medication as costs are rising at an alarming rate. Monitoring prescription costs and maintaining a formulary helps Bankmed keep premiums down while offering a high level of benefits. In addition, our doctors and pharmacists stay current on the most recent developments in medication. We continually update our formulary based on the latest research.
Benefits for chronic medication on the Basic and Essential Plans are restricted to chronic medication formularies. Find out if your medication is on the formulary for your Plan.
Although Bankmed only covers one month's supply of medication at a time, you may apply for an exception to be made when you plan to travel outside the borders of South Africa for an extended period. To apply for this, please complete and submit this form with a copy of your return airline ticket as your proof of travel to enquiries@bankmed.co.za, at least three to five days before departure. If approved, you will receive an amended Chronic Authorisation letter to give to your pharmacist. This will enable him/her to claim the extended supply from Bankmed. Please remember to notify us of your return to South Africa, so that we may reinstate your original authorisation.
- Smartphone App: Use the camera on your phone to take a picture of the claim. Use your phone to scan the QR code
- Upload: scan and upload your claims. Upload your claim now
- By post to: Bankmed Claims, PO Box 1242, Cape Town, 8000
- By e-mail to: claims@bankmed.co.za
- By fax to: 021 527 1940
Claims must reach Bankmed within four months of the treatment date otherwise Bankmed will not be liable to provide benefits.
All claims must be checked for correctness and must be clearly legible.
On receipt of your account from the Healthcare Professional, check that the following information appears on the account:
- Your membership number
- Your surname and initials
- The patient's first name, surname and dependant code
- Name of your Plan type
- The name and practice number of the supplier of the service
- The nature and cost of treatment
- The referring doctor's practice number on specialist's accounts
- The tariff code that relates to the healthcare service you received
- The ICD-10 (diagnostic) code that relates to the healthcare service you received
- Proof of payment, if you have paid the account yourself
Should you wish to receive a notification whenever a claim has been received and processed, you can register by logging in to www.bankmed.co.za or by using the Bankmed App, using your membership number. You may then choose to either receive your notification via e-mail or SMS. Once the claim has been processed and paid, you will receive a claims statement either in the post or by e-mail, depending on the option you selected.
Should you wish to do this now, click here.
Checking your claims statement
Your claims statement is one of the most important documents you will receive from Bankmed. It is as important as your bank statement. Check your Bankmed statement as carefully as you would your bank account. By doing this, you will help us to detect fraud and to manage your benefits in the most efficient way.
Please check your statement to ensure that:
- The claims on the statement are for services that you and/or your registered dependants received
- Bankmed has processed all claims for services rendered to you and your dependants (and that you have submitted all of your claims within four months of the date the service was received)
- The correct dependant code as shown on your membership card is reflected opposite each claim
You can download your claims statement from the website.
If you notice any errors or have a query, please contact Bankmed Customer Services on 0800 BANKMED (0800 226 5633).
Income tax records
You should keep your claims statements for income tax purposes.
COVID-19 is an infection caused by a type of Coronavirus. The primary means of spread seems to be saliva-droplet based spread. This is similar to the common cold and seasonal flu. COVID-19 appears to be more infectious than the seasonal flu with an infection rate that is 1.5 to 2 times higher than seasonal flu. Reassuringly, however, the vast majority of people who contract COVID-19 experience only mild symptoms, including a potential fever, a cough and shortness of breath.
You can check the live tracker on this illness for updates on confirmed cases. You can also view daily situation reports to keep informed.
The primary symptoms include:
- Fever
- Cough
- Shortness of breath or difficulty breathing
COVID-19 spreads quickly, through:
- Coughing or sneezing - people could catch COVID-19 if they are standing within one metre of a person who has the illness, by breathing in droplets coughed out or exhaled by the ill person
- Close personal contact, such as when shaking hands or touching others
- Touching an object or surface on which the virus is found (after a sick person coughs or exhales close to these objects or surfaces such as desks, tables or telephones), then - before washing the hands - touching the mouth, nose, or eyes
Healthcare Professionals can only treat the symptoms of COVID-19 as they present. No specific therapy is effective against the virus itself. If you meet any of the criteria listed below, you must seek medical care early and share your previous travel history with your Healthcare Professional.
When to seek medical care:
- If you have acute respiratory illness and suddenly have a cough, sore throat, shortness of breath or fever (>= 38°C)
- Were in close contact with someone who had a probable or confirmed case of COVID-19 infection
- If you have travelled to areas with presumed ongoing community transmission of COVID-19
- If you have worked in or attended a health care facility where patients with COVID-19 infections were being treated
- If you have been admitted with severe pneumonia of unknown aetiology
People who contract the COVID-19 may take anywhere from one to 14 days to develop symptoms. Even if you have not recently travelled to a COVID-19-affected region, or had contact with an individual who has been affected by the illness, you must still inform your Healthcare Professional if you meet the criteria listed above. A virtual consultation is an excellent way to consult with your Healthcare Professional.
Bankmed, in partnership with our Administrator, has introduced a range of initiatives to support our members during COVID-19. These initiatives included detailed analytics and reporting to identify and understand the risks and needs of our members, new benefits to provide full financial indemnity against COVID-19, initiatives to protect high risk members against the severe effects of COVID-19, home care and monitoring for early detection of signs of deterioration, digital services for remote consultation and doctor support.
As the pandemic has progressed, much like the rest of the world, the healthcare system has experienced high volumes of COVID-19 related admissions, placing significant strain on ICU bed capacity. In regions where the capacity of hospital beds - particularly ICU beds - comes under strain, Bankmed will do everything in our power to ensure that every single member who requires ICU care, receives this at the highest standards. If necessary, this includes contingency planning to transport members to an available ICU bed, where appropriate. We are fortunate that as we have seen volumes peak recently in various provinces, including the Western cape, Eastern cape and Gauteng, there have been sufficient beds in the private hospitals to accommodate all patients needing urgent care.
Our Administrator, is working very closely with the private hospital groups; with whom we have longstanding relationships. This includes regular check-ins on the capacity of the private hospitals, and particularly the availability of ICU beds for urgent cases. In the event that ICU bed capacity is seen to be threatened or diminishing to dangerously low levels, we will work with the hospitals, the treating doctors, and the members' families to move members being treated for non-COVID related conditions, to ICUs where sufficient surplus capacity exists. This would serve to free up additional capacity, in the pressurised and overloaded ICUs.
We are optimistic that as a result of the healthcare infrastructure contingencies, and extra resources added during the lockdown, that there will be sufficient healthcare resources to meet the country's and our members' needs. We do, however, encourage preventative and social distancing measures, including reminders of available benefits and services that our members have access to, in the context of the rising infection rate.
As the COVID-19 pandemic progresses, emerging experience from other parts of the world, as well as data highlights the importance for members to understand and manage their health risks during COVID-19.
Bankmed's response is to enhance our COVID-19 basket of care with an additional Hospital at Home benefit. The Hospital at Home benefit was introduced to assist with capacity constraints and to alleviate pressure from the in-hospital setting for members who could be treated safely at home.
The Hospital at Home benefit is open to high-risk members who test positive for COVID-19 and are mildly symptomatic and at risk for hospitalisation. Additionally, had these members been admitted, they would have met the criteria for general ward admission, but not High Care or ICU.
The Hospital at Home benefit consists of two components:
1. Remote Monitoring
Bankmed provides members who require monitoring with daily check-in calls from the remote monitoring system, 24-hour monitoring by the Care team, oversight by the treating Healthcare Professional, and a biosensor patch to remotely monitor vitals and alerts for out of range readings.
1.1 Qualifying criteria:
- High risk patients >35 years with comorbidities +/- obesity who are COVID-19 positive are symptomatic and at increased risk of hospitalisation
1.2 Criteria for GP vs Physician monitoring:
- Based on admitting/referring Healthcare Professional for remote monitoring
2. Hospitalisation in the Home
Bankmed provides members with acute in-patient treatment at home to avoid hospitalisation. This benefit also covers members who are deemed medically stable by their treating provider to be discharged from hospital earlier to continue their treatment at home.
2.1 Qualifying criteria:
- Patients >18 years in Stage 2 COVID-19 infection who meet criteria for hospitalisation
2.2 Criteria for GP vs Physician monitoring:
- For hospitalisation at home only physicians eligible
How does a member access this benefit?
Contact your Healthcare Professional and they will make a decision as to whether you qualify to access this benefit based on the above mentioned criteria. If you do, they will contact Bankmed and begin the preauthorisation process.
For more information call 0800 226 5633 or email enquiries@bankmed.co.za.
Answers to important questions about COVID-19 vaccines
Q: How do we overcome anti-vaccine sentiment and myths around vaccination?
A: It's important that we confront anti-vaccine sentiment - and any misinformation around COVID-19 vaccines - with credible content and well-considered responses. First, the approved vaccines have been developed by big and well-established companies that have been around for decades. They employ thousands of scientists and Healthcare Professionals, and these are the people who have developed the vaccines, giving us a significant sense of the calibre of people who are working on vaccine development.
There are many excellent reasons why these vaccines have been developed so quickly, including unprecedented access to funding, the global priority placed on their development and access to thousands of trial participants. These vaccines have also undergone rigorous testing in every phase of the clinical trial process and been tested across massive groups of participants (up to 60 000 people) once they have reached the phase 3 clinical trial phase. The results of these clinical trials so far demonstrate high levels of efficacy (most well over 90%) and safety.
Keep in mind that COVID-19 vaccines are only approved if two requirements are met:
- The vaccine is safe
- The vaccine is effective
South Africa also has a very strong regulator, namely the South Africa Health Product Regulatory Authority (SAPHRA). This regulator is responsible for approving all medication and vaccines for use in South Africa and conducts an in-depth and extensive scientific and analysis of the safety and efficacy clinical data of all medical products before approving their use in South Africa.
Also, getting vaccinated is a far more 'natural' way of preventing disease than taking other pharmaceutical products.
Q: We will have access to a number of different vaccines. Are they all equal in efficacy?
A: All the vaccines that we will have access to in South Africa are required to meet a minimum standard of efficacy to be effective on a population basis. And, the COVID-19 vaccines that have been approved for use are well above these levels of efficacy, at around 90% for most. Where a two-dose vaccine regimen is indicated, people will receive the same vaccine in the first and second round.
Q: Will it be compulsory to be vaccinated?
A: People cannot be forced to be vaccinated. The COVID-19 vaccine is a medical treatment, and medical treatments cannot be made compulsory. South Africa's constitution protects our rights in this regard and President Cyril Ramaphosa has reiterated this many times. However, people will be strongly encouraged to be vaccinated to protect themselves and those they interact with, whether loved ones or colleagues, or others in the wider community.
Q: Can employers access COVID-19 vaccines themselves and run their own vaccine drives?
A: There are two parts to this answer:
- It's critical that we drive equitable access to vaccination. We must all follow the national rollout plan. This means that all people will have the option to be vaccinated according to where they fall into South Africa's three-phased rollout. In our view, it would be completely unethical and unfair for a young, healthy person to access a COVID-19 vaccine ahead of a healthcare worker, an at-risk person or an older person. Vaccine access cannot be linked to one's socio-economic status or resources. We must follow our country's rollout plan and ensure fair, carefully considered access to vaccines
- Employers cannot legally import COVID-19 vaccines. Until a vaccine is registered in South Africa and unless an entity has a licence to import and distribute this vaccine, it is illegal to import any parallel medical products or vaccines. Additionally, if an employer imported vaccines without the necessary approvals and licences and someone receiving that vaccine experienced an adverse reaction, the consequences for the employer would be dire. We ask that employers work alongside us and our Business for South Africa colleagues to accelerate the procurement of reliable, safe vaccines to all South Africans
Q: Will we need a COVID-19 vaccination each year?
A: We do not know yet. We are not sure how long vaccine-induced immunity will last and what levels of immunity the vaccine will stimulate. We understand short-term efficacy but need more data to understand long-term immunity. We certainly hope that this vaccine will not be needed as frequently as the flu vaccine (which is needed annually due to the speed at which influenza virus variants develop). However, it's important that the data be analysed over the long term before we can answer this question.
Q: How serious are COVID-19 vaccine side effects?
A: We have seen very minor or no side effects in other countries where vaccine rollout process are under way. The most common side effects are some pain around the injection site that lasts a few hours and resolves within a day, as well as other flu-like side effects that also resolve very quickly and are indicative of the immune response taking place.
The more severe adverse events are extremely rare. In most instances, adverse reactions linked to vaccines are far lower than adverse events linked to taking medicines. As evidence of this, latest statistics indicate just 2.8 severe adverse events per million vaccinations for the Moderna vaccine. This means the likelihood of severe adverse events is extremely low and that they are extremely rare.
There will also be health professionals on site at every vaccination centre to immediately manage any potential adverse event that might occur.
Out-of-hospital cover
The WHO Global Outbreak Benefit is available to all members of Bankmed during a declared outbreak period. The benefit covers you for the COVID-19 vaccine as well as a defined basket of care for out-of-hospital healthcare services related to COVID-19.
As part of the basket of care, you are covered for:
- COVID-19 vaccine and the administration of the vaccine
- Screening consultations with a network GP (either virtual consultations, telephone or face-to-face)
- COVID-19 PCR and Rapid Antigen screening tests (only two tests) if referred by your Healthcare Professional, or if referred by a network GP
- A defined basket of pathology tests for COVID-19 positive members
- A defined basket of x-rays and scans for COVID-19 positive members
- Supportive treatment, including medication and at-home monitoring device to track oxygen (pulse oximeter) saturation levels for at-risk members who meet the clinical entry criteria
The Hospital at Home benefit is open to high-risk members who test positive for COVID-19 and are mildly symptomatic and at risk for hospitalisation.
This benefit is available on all Plans and is covered by Bankmed as a Prescribed Minimum Benefit (PMB) without using your day-to-day benefits, where applicable.
Cover is subject to Bankmed's preferred providers (where applicable), protocols and the treatment meeting Bankmed's entry criteria and guidelines. Any recommended treatment and healthcare services that are not included in the basket of care may be covered according to the benefits available on your chosen Plan in line with Bankmed Scheme Rules and clinical guidelines or in accordance with Prescribed Minimum Benefits (PMBs), where applicable.
In-hospital treatment
In-hospital treatment related to COVID-19 for approved admissions is covered from the Hospital Benefit based on your chosen Plan and in accordance with Prescribed Minimum Benefits (PMB) where applicable.
Cover for COVID-19 vaccine
The WHO Global Outbreak Benefit is available to all members of Bankmed during a declared outbreak period. The benefit provides cover for the COVID-19 vaccine as well as a defined basket of care for out-of-hospital healthcare services, related to the outbreak disease.
The COVID-19 vaccine and administration of the vaccine are covered as Prescribed Minimum Benefits (PMB) without using your day-to-day benefits.
All Bankmed members 18 years and older will be covered for the vaccine, in accordance with the prioritisation framework and the three-phase roll-out plan as established by the Ministerial Advisory Committee and National Department of Health.
Getting vaccinated
You will be required to register on the National Department of Health's Electronic Vaccination Data System (EVDS), and make use of one of the accredited vaccination sites. The list of accredited facilities will be published by the National Department of Health.
Bankmed members on all plan types are covered for COVID-19 test. The cost of the test is covered from the Insured Benefits (RISK), as long as the test meets the National Institute for Communicable Diseases (NICD) protocol and you're referred by a Healthcare Professional. You are covered for the test whether the result is negative or positive.
You are also covered for a COVID-19 test if you've received authorisation to go to hospital, as long as a Healthcare Professional refers you.
COVID-19 is diagnosed by taking a sample from your respiratory tract - either your nose, throat or chest.
If you have symptoms of COVID-19 or you may have been exposed to a COVID-19 infection, you need to consult with a doctor. If necessary, they will refer you for testing. Call your doctor or book a virtual consultation rather than going to their consulting rooms first. Online doctor consultations provide a safe alternative to face-to-face consultations for patients and doctors.
The below information aims to provide members with simple guidelines when needing an ambulance or hospital admission for COVID-19.
- If the member needs an ambulance, they must call 0860 999 911 and Netcare 911 will assist.
- Netcare 911 will send a response car to access the member's vitals and based on the outcome they will transport the member to a casualty unit.
- From there, if an admission is needed, Netcare 911 will source bed availability via the Joint Operation Centre (JOC) - all main hospitals are linked via the JOC.
- The member also has the option, if possible, to drive themselves to the closest casualty unit and not have to wait for an ambulance.
- Members must only go to a casualty unit if they are having trouble breathing or have the ability to record statistics which show they are deteriorating. If they are feeling flu-like symptoms, they must make contact with their doctor.
- If their doctor believes an admission is needed, a bed will be sourced. Members will also be transported out of the province to the extent that this is required.
A deductible is a co-payment (amount you must pay out of your own pocket) payable by a member on admission to hospital.
Deductible applicable to a specific list of treatment/procedures carried out in a Day Surgery Network
The following conditions/ procedures will NOT attract a deductible at a Day Surgery Network (list of conditions/ procedures applies to DSP only):
- Adenoidectomy
- Arthrocentesis
- Cataract Surgery
- Cautery of vulva warts
- Circumcision
- Colonoscopy
- Cystourethroscopy
- Diagnostic D and C
- Gastroscopy
- Hysteroscopy
- Myringotomy
- Myringotomy with intubation (grommets)
- Nasal cautery
- Nasal plugging for nose
- Proctoscopy
- Prostate biopsy
- Removal of pins and plates
- Sigmoidoscopy
- Tonsillectomy
- Treatment of Bartholins cyst/gland
- Vasectomy
- Vulva/cone biopsy
- Oesophagoscopy
- Simple abdominal hernia repair
- Eye procedures
- Other eye procedures: removal of foreign body, vitrectomy
- Gynaecological procedures
- Laparoscopic gynaecological proceduresy
- Orthopaedic procedures
- Arthroscopy, arthrotomy, knee, shoulder, elbow, hand, wrist), arthrodesis (hand, wrist)
- Minor joint arthroplasty (intercarpal, carpometacarpal and metacarpophalangeal, interphalangeal joint arthroplasty
- Tendon and/or ligament repair, muscle debridement, fascia procedures (tenotomy, tenodesis, tenolysis, repair/reconstruction, capsulotomy, capsulectomy, synovectomy, excision tendon sheath lesion, fasciotomy, fasciectomy).
- Treatment of simple closed fractures and/or dislocations, removal of pins and plates.
- Incision and drainage/excision of abscess and/or cyst/tumour: subcutaneous tissue, soft tissue, bone, bursa
- Biopsies: subcutaneous tissue, soft tissue, muscle, bone
- Treatment of closed fractures and/or dislocations, removal of pins and plates
If the member chooses to have the abovementioned procedures/treatments performed in a non-network Day Surgery facility or in a hospital, the member will be liable for a R4100 deductible per admission.
Important note for Essential Plan members: No access to full list of treatments/procedures listed above. Cover is limited to PMBs. If underlying diagnosis is a PMB, member qualifies for treatment.
A deductible will apply to all beneficiaries on the Traditional, Comprehensive and Plus Plans are admitted to hospital or a day clinic for dental treatment. The deductible applies upfront and will need to be settled at the facility prior to admission.
Day clinic: R310 deductible
Hospital: R2 295 deductible
Yes, if you are on a Plan with a Medical Savings Account you may claim this amount, but you will be required to pay the amount upfront to the hospital and claim it back from Bankmed afterwards. Members on the Core Saver, Comprehensive and Plus Plans can only claim this back if they have accumulated savings funds available. Accumulated savings refers to the unused portion of savings carried over from previous years, plus that portion of the current year's savings allocation for which contributions have already been paid to the Scheme. Deductibles cannot be refunded from upfront savings allocations, for which contributions have not yet been paid to the Scheme.
Emergency ambulance services are provided through Bankmed Emergency Services.
If you are in a crisis situation and require medical assistance, contact Bankmed Emergency Services on 0860 999 911.
Bankmed members may use Bankmed Emergency Services 24-hour medical advice line, which provides quick and professional advice if you are unsure of treatments for certain conditions or are interested in self-help care.
If you require emergency assistance using an ambulance service, you should contact Bankmed Emergency Services as soon as you require this service.
The pre-authorisation process and Managed Care Programmes ensure that members receive the most cost-effective and appropriate care for their illness. This also allows the cost of hospitalisation, medication and treatment to be managed for the benefit of our members.
Pre-authorisation is required for planned hospital admissions, MRI/CT scans, radionucleotide scans, chronic medication and other major medical expenses as specified in the Benefit and Contribution Schedule for various Plans.
If you do not obtain pre-authorisation prior to incurring expenses for these specified events, you may be exposed to unfunded liabilities (penalties or out-of-pocket payments), or you could even be liable for the full account.
It is therefore vital that you obtain pre-authorisation where indicated as a requirement in your benefit schedule, before incurring any expenses.
To obtain pre-authorisation for a hospital admission, MRI/CT scan or radionucleotide scan:
- Telephone (toll free from a Telkom landline): 0800 BANKMED (0800 226 5633)
- Fax: 011 539 2191
- E-mail: treatment@bankmed.co.za
Pre-authorisation for hospital admission refers to the clinical appropriateness of the admission and to the length of stay. It is not a confirmation of available or unlimited benefits. You must always refer to your Benefit and Contribution Schedule for the benefit limits that may apply.
For hospital pre-authorisation
Before calling for a hospital pre-authorisation, you will need to have the following information available:
- Name and contact details of main member
- Initials, surname and date of birth of the patient (main member or dependant)
- Bankmed membership number
- Name and practice number of treating doctor
- Name and practice number of hospital where patient is to be admitted
- Proposed duration of hospitalisation
- Date and time of admissions
- CPT4 (procedure) code - remember to ask your doctor for this
- ICD-10 (diagnosis) code - remember to ask your doctor for this
Pre-authorisation for a MRI, CT or radionucleotide scan
It is essential that you obtain pre-authorisation before an MRI, CT or a radionucleotide scan is performed. Before calling for authorisation, you will need to have the following information available:
- Name and contact details of principal member
- Initials, surname and date of birth of the patient (main member or dependant)
- Bankmed membership number
- Name and practice number of referring doctor
- Name and practice number of treating doctor (radiologist)
- CPT4 (procedure) code - remember to ask your doctor for this
- ICD-10 (diagnosis) code - remember to ask your doctor for this
An MRI (or magnetic resonance imaging) scan is a radiology technique that uses magnetism, radio waves and a computer to produce images of body structures. MRI scans are painless and do not involve X-ray radiation.
Source: www.medicinenet.com
Nuclear scans use radioactive substances to view structures and functions inside your body. Nuclear scans involve a special camera that detects energy coming from a radioactive substance called a tracer. Although tracers are radioactive, the dosage is small.
CT imaging uses special X-ray equipment to produce multiple images of the inside of a body. CT scans are used to examine internal organs, bone, soft tissue and blood vessels.
Yes, always request authorisation for these services. When you send your request please forward a medical motivation, treatment plan and quotation for approval to enquiries@bankmed.co.za or fax it to 021 539 2192.
For everything you need to know about claiming for foreign claims, we recommend that you review this page.
Although Bankmed only covers one month's supply of medication at a time, you may apply for an exception to be made when you plan to travel outside the borders of South Africa for an extended period. To apply for this, please complete and submit this form and e-mail it with a copy of your return airline ticket as your proof of travel to enquiries@bankmed.co.za at least three to five days before departure. If approved, you will receive an amended Chronic Authorisation letter to give to your pharmacist. This will enable him/her to claim the extended supply from Bankmed. Please remember to notify us of your return to South Africa, so that we may reinstate your original authorisation.
If you suspect that fraud or abuse has occurred or you have become aware of potential fraud or abuse that may affect the Scheme, please call the Bankmed Toll-Free Fraud Hotline anonymously on 0800 004 500. This service is managed by a third party and the caller's identity is fully protected.
Your identity is fully protected and you will remain anonymous.
The law provides that a late-joiner penalty may be imposed on a member or his/her adult dependant who is 35 years of age or older at the date of application and who:
- Did not belong to a registered medical scheme on 1 April 2001 or
- Belonged to a registered medical scheme on 1 April 2001 but experienced a break in cover of three or more consecutive months since 1 April 2001
The late-joiner penalty is provided for in legislation and is calculated as follows:
The penalty to be applied depends on the number of uncovered years (as indicated below) and is calculated as a percentage of the monthly contribution (excluding savings) applicable to the late joiner. If, for example, the total contribution for a late-joiner is R1 000 and 25% of that (i.e. R250) is allocated to savings, the late joiner penalty will be calculated as a percentage of the balance, i.e. as a percentage of R750.
| Uncovered years | Penalty to be applied |
|---|---|
| 1 - 4 years | 0.05 x contribution (excluding savings) |
| 5 - 14 years | 0.25 x contribution (excluding savings) |
| 15 - 24 years | 0.50 x contribution (excluding savings) |
| 25+ years | 0.75 x contribution (excluding savings) |
Example:
- You are 50 years old
- You do not join Bankmed from the first date that you are eligible to do so
- You apply for membership in April 2012
- The last time you were on a medical scheme was December 2011
- You were previously on a medical scheme (or schemes) for a combined total period of four years
It is important that you demonstrate membership of all previous Schemes when you apply to join Bankmed, as this can affect the calculation of the late joiner penalty. The greater the period of cover you can demonstrate, the lower the penalty (if a penalty applies).
Calculation:
Please note that to ensure that the correct contribution and/or penalty is charged (if applicable), we require the following:
- Your application form to be completed in full and
- Proof of cover on all previous medical schemes, i.e. certificate(s) of membership to be provided where requested on the application form
The penalty amount is percentage driven therefore it will increase or decrease:
- As and when the Scheme announces an overall contribution increase or decrease
- If a salary adjustment results in a change in salary category of the main member or
- When you change to a different plan (with different contributions)
The percentage added to the contribution is not a once-off fee and will apply for the duration of a beneficiary's membership.
The Medical Savings Account (MSA) only applies to members on the Core Saver, Comprehensive or Plus Plans.
The MSA is an upfront benefit we provide you with at the beginning of the year. This amount is pro-rated by the number of months remaining if you join aft er 1 January. You may use your MSA to pay for day-to-day medical costs like Healthcare Professional visits, x-rays and dentist visits. Legislation prevents Bankmed from funding PMBs from your Medical Savings Account even when requested by you. This advanced amount will be paid back by you as part of your monthly contribution to the Scheme. The money in your MSA that you haven't used by the end of the year is carried over to the following year.
Please note that, as contributions are only payable for a maximum of three children, the Medical Savings Account allocation will also be limited to a maximum of three children (even if you have four or more children registered as your dependants).
- It gives you control over your day-to-day healthcare expenses
- Unused savings balances may be carried over from one year to the next
- Bankmed awards interest (once a year) on positive savings balances
- You can use savings to pay for valid claims when your available insured benefits are depleted
Since the money in your Medical Savings Account is your money to spend wisely, subject to legislation around what this money may be used for, you may use a service provider of your choice for benefits that will be paid from your Medical Savings Account. However, claims will still be paid according to Bankmed Rules, as long as there is money available in your Medical Savings Account. If there is no money available in your Medical Savings Account, you will have to pay the outstanding amount directly to the service provider.
If there is money available in your Medical Savings Account at the end of the benefit year (i.e. 31 December), the balance will be brought forward after all accounts have been settled for the previous year. This amount will then be credited to your account at the end of April or the beginning May for use in the current benefit year.
Your claims will be processed according to the date of treatment and not the date on which Bankmed received the claim.
Claims from the previous benefit year cannot be paid from the current year's Medical Savings Account.
However, if you have a positive balance in your Medical Savings Account, you may use the balance brought forward from the previous year to settle claims for the current benefit year.
You may use your Medical Savings Account to pay for excess amounts on any claim. This will happen automatically unless you notify the Scheme that you do not want such amounts to be paid from your Medical Savings Account.
You can find out your Medical Savings Account balance is by using one of the following channels:
- Bankmed website: www.bankmed.co.za
- Bankmed mobile App: http://www.bankmed.co.za
- Bankmed Customer Services: 0800 BANKMED (0800 226 5633)
- IVR/self-direct telephone facility
- Your most recent claims statement
Providers, as per Bankmed Rules, may submit claims for services rendered to you up to four months after the date of service. Consequently, Bankmed has to provide for any claims you may have incurred and that may still be outstanding in this time. Therefore, any credit balance in your Medical Savings Account (if applicable) will only be refunded to you or transferred to your new scheme five months after you terminate your membership
If you have remaining funds in your Medical Savings Account six months after termination, Bankmed must (by law) transfer these to your new Scheme, unless your new Scheme or Plan does not provide for a Medical Savings Account, in which case the remaining funds must be paid to you (and will be taxable in your hands).
Therefore, when you resign you must inform Bankmed what to do with your savings balance following your resignation. If your new Scheme or Plan provides for a savings component, you must provide us with the banking details of such scheme as well as the reference to be used on the deposit slip when transferring these funds (for your benefit) to your new scheme.
It is possible that when you leave Bankmed, you may owe the Scheme money in respect of advances on your Medical Savings Account (e.g. if you resign during the year and have already used the full year's savings allocation) or for any other amounts owing to the Scheme. These amounts will be recovered from you by direct debit to your bank account in the month following your resignation.
Interest is awarded at 50% of Scheme money market earnings rate (net of fees). Interest is calculated monthly on the previous month's opening balance and credited to members once a year in February. In the event that interest is earned and awarded, the values will reflect in the IT3(b) that is issued with the Tax Certificate.
If no interest is earned and awarded, an IT3(b) will not be issued.
To find out more about how interest is calculated, click here.
Obtain an application form either from your HR Department or by downloading it. Complete the application form in full and submit it to your HR Department with:
- A certificate of membership, indicating the resignation date from your previous medical scheme (if applicable)
- Any additional documentation/certificates as requested on the application form (where applicable)
Kindly note:
The 2024 Application for Membership form can be completed by typing the required information within the highlighted areas. Once completed, you will need to print the form and sign it wherever personal signatures are required.
It is essential that the application form be completed in full and that all supporting documentation is correctly submitted and certified by your employer. Please take extra care to provide a full membership history and proof of cover with previous medical schemes where requested to do so on the application form.
As it is against the law to belong to more than one Scheme at the same time, please ensure that you terminate membership with your previous Scheme (if applicable) prior to joining Bankmed.
Membership is open to any person in the service of an employer who is contracted to Bankmed.
If you join Bankmed from your employment date, you will be entitled to benefits as soon as you join.
Waiting periods (during which contributions will be payable) and/or late-joiner penalties may apply if you join Bankmed on a date other (later) than your employment date. Please refer to the section below on waiting periods and later-joiner penalties for more information.
The following members of your immediate family may qualify as dependants.
Spouse
Your spouse to whom you are legally married. If you are divorced, your former spouse cannot be registered as a dependant.
Partner
A person with whom you have entered into a civil union in terms of the Civil Union Act 17 of 2006 or a person with whom you have a committed and serious relationship, similar to a marriage, based on objective criteria of mutual dependency and a shared and common household, irrespective of the gender of either party.
Dependent children*
"Dependent" in relation to children (including grandchildren), means they are:
- Dependent on you for family care and support (i.e. financially dependent)
- Dependent on you due to physical or mental disability, or
- Full-time students at a registered tertiary institution
Proof of dependence for a dependent child or grandchild must be supplied to the Scheme each year, starting from the month before the dependant's 27th birthday.
Only dependent children and grandchildren (children who are unable to support themselves) may be registered as your dependants on Bankmed. This means that a child who is no longer dependent on you (whether due to marriage or through his/her having gained permanent employment), does not qualify. You must inform Bankmed of any event that would no longer qualify your child as your dependant.
*"Children" means your child, stepchild, legally adopted child, foster child, grandchild or a child who has been placed (or is in the process of being placed) in your custody, or the custody of your partner or spouse.
The following contributions are payable for a dependent child (including a grandchild):
- Child rates until the end of the month in which he/she turns 23
- Adult rates from the month following his/her 23rd birthday
Special dependants
A special dependant is a parent, parent-in-law, parent of a civil union partner, brother or sister for whom you are liable for family care and support.
Please note that the above family members do not automatically qualify as your dependants. You need to demonstrate to Bankmed's satisfaction that you are liable for family care and support of such a special dependant, as opposed to merely taking a decision to care for him/her, and that he/she is unable to take care of himself/herself.
Adult contribution rates will apply to a brother/sisters for whom you are liable for family care and support, from the month following the month in which he/she turns 23. Proof of dependence in respect of a brother/sister (once recognised as your dependant) must be supplied annually to the Scheme from the month before his/her 27th birthday.
Grandparents, nephews, nieces and any other family members not listed as 'special dependents' do not qualify as your dependants. A child who is not your biological child, stepchild, adopted child or legally fostered child will only qualify as your dependant if legal (court-appointed) guardianship exists, in which case he/she will be regarded as your "child".
Any of the following events (this list is not comprehensive) may affect your membership and/or contributions and you are requested to advise us immediately if:
- Any of your dependants are no longer eligible for dependant membership (e.g. due to divorce or termination of a domestic partnership)
- A child dependant is no longer dependent on you (e.g. due to marriage or obtaining full-time employment)
- You retire
- You are retrenched or made redundant
- There is a change in your marital or domestic status and you wish to add a dependant
Should you leave your employer during the course of the month (i.e. not at the end of the month), you will be entitled to membership until the end of the month concerned. A full month's contribution will be payable for your last month of membership (even if you leave the employer during the month).
A Personal Health Assessment is a health screening tool that highlights any current health risk. Once any risk is identified, it will then need to be confirmed by your general practitioner. This assessment can be conducted by an accredited Bankmed general practitioner, pharmacy, biokineticist and nurse.
Bankmed Personal Health Assessments are paid for from the insured pool of funds of your Plan. The Insured Benefit is the portion of your Scheme that does not affect your day-to-day benefits. This means that it is not paid from your Medical Savings Account (should you be on the Core Saver, Comprehensive or Plus Plans) and it also does not affect any of your consultation limits (should you be on the Essential, Traditional or Basic Plans).
Bankmed benefits make provision for one Personal Health Assessment per beneficiary per annum over the age of 18 years old.
You can download and print a Personal Health Assessment & HIV/AIDS Counselling and Testing form.
Prescribed Minimum Benefits (PMBs) are a set of defined benefits to ensure that all medical scheme members have access to certain minimum healthcare services, regardless of the benefit option they select. The aim is to provide people with continuous care to improve their health and wellbeing and to make healthcare more affordable.
Prescribed Minimum Benefits are a feature of the Medical Schemes Act 131 of 1998, in terms of which medical schemes are required by law to cover the costs related to the diagnosis, treatment and care of:
- Any emergency medical condition (refer to "What are emergency conditions?" below for more information)
- A limited set of 270 medical conditions, defined in the Diagnosis Treatment Pairs (these conditions are listed in the "Council for Medical Schemes' Consumer Guide: Prescribed Minimum Benefits and Chronic Medication" which you may access below by clicking on the "Access" link)
- 25 chronic conditions (defined in the Chronic Disease List).
When deciding whether a condition is a Prescribed Minimum Benefit, the doctor should consider only the symptoms and not at any other factors, such as how the injury or condition was contracted. This approach is called diagnosis-based. Once the diagnosis has been made, the appropriate treatment and care is decided upon as well as where the patient should receive the treatment (at a hospital as an outpatient or in a doctor's rooms).
Access the Council for Medical Schemes' Consumer Guide: Prescribed Minimum Benefits and Chronic Medication.
An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or surgery. If the treatment is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts or even death.
In an emergency it is not always possible to diagnose the condition before admitting the patient for treatment. However, if doctors suspect that the patient suffers from a condition that is covered by Prescribed Minimum Benefits, the medical scheme has to approve treatment. Schemes may request that the diagnosis be confirmed with supporting evidence within a reasonable period of time.
The Regulations of the Medical Schemes Act provide a long list of conditions identified as Prescribed Minimum Benefits. The list is in the form of Diagnosis and Treatment Pairs (DTPs).
A Diagnosis and Treatment Pair links a specific diagnosis to a treatment and therefore broadly indicates how each of the approximately 25 Prescribed Minimum Benefit conditions should be treated. The treatment and care of Prescribed Minimum Benefit conditions should be based on healthcare that has proven to work best, taking affordability into consideration. Should there be a disagreement about the treatment of a specific case, the standards (also called practice and protocols) in force in the public sector will be applied.
The treatment and care of some of the conditions included in the Diagnosis and Treatment Pairs may include chronic medication, e.g. HIV-infection and menopause management. In these cases, the public sector protocols will also apply to the chronic medication.
To manage risk and ensure appropriate standards of healthcare, so-called treatment algorithms were developed for Chronic Disease List conditions.
The algorithms, which have been published in the Government Gazette, can be regarded as benchmarks, or minimum standards, for treatment. This means that the treatment your medical scheme must provide may not be inferior to the algorithms.
Should you have one of the 25 listed chronic diseases, your medical scheme not only has to cover medication, but also doctors' consultations and tests related to your condition. The scheme may make use of protocols, formularies (lists of specified medications) and Designated Service Providers to manage this benefit.
The Chronic Disease List (CDL) specifies medication and treatment for the 27 chronic conditions that are covered as Prescribed Minimum Benefits:
- Addison's disease
- Asthma
- Bipolar mood disorder
- Bronchiectasis
- Cardiac failure
- Cardiomyopathy
- Chronic obstructive pulmonary disease
- Chronic renal disease
- Coronary artery disease
- Crohn's disease
- Diabetes insipidus
- Diabetes mellitus type 1
- Diabetes mellitus type 2
- Dysrhythmias
- Epilepsy
- Glaucoma
- Haemophilia
- Hyperlipidaemia
- Hypertension
- Hypothyroidism
- Multiple sclerosis
- Parkinson's disease
- Rheumatoid arthritis
- Schizophrenia
- Systemic lupus erythematosus
- Ulcerative colitis
Are all Prescribed Minimum Benefit conditions automatically covered or do I need to apply for cover?
On Bankmed, these benefits are subject to pre-authorisation, and the application of clinical protocols. This means you must apply for these benefits or you may lose your entitlement to them.
Certain benefits are also only covered in full if you use GP Entry Plan Network Providers (Essential and Basic Plans) and Bankmed Network General Practitioners and/or Bankmed Network Pharmacies (other Plans) to access relevant benefits for chronic medication and consultation services. Refer to the Benefit and Contribution Schedule for details.
Where sub-limits are specified for chronic medication, these are first used to pay for all chronic medication (including Prescribed Minimum Benefit conditions) and thereafter continued benefits are only provided as Prescribed Minimum Benefits.
Obtain as much information as possible about your condition and the medication and associated treatments.
If there is a generic medication available, do your own research to find out whether there are any differences between the generic and the branded or original medication.
Do not bypass the system: if you must use a general practitioner to refer you to a specialist, then do so. Make use of Bankmed's contracted providers (Designated Service Providers) as far as possible. Use the Scheme's listed medication for your condition unless it is proven to be ineffective.
Make sure your doctor submits a complete account to the Scheme. It is especially important that the correct diagnosis code (ICD-10 code) is reflected.
Follow up and check that your account is submitted:
- Within five months after the service was provided (accounts older than four months are not paid by medical schemes) and
- Paid within 30 days after the claim was received
A waiting period is a fixed period during which contributions are payable, but some or all claims may be excluded from benefits.
Waiting periods are provided for in legislation and offer Schemes and their members limited protection against the potential risk of anti-selection by new applicants. Anti-selection is a general term that, in the context of a medical scheme, refers to certain decisions or behaviours by prospective members that could impact negatively on the Scheme.
Bankmed's Rules provide for two types of waiting periods when a member/dependant joins the Scheme:
- A general waiting period of three months
- A condition-specific waiting period of 12 months for certain pre-existing conditions (9 months for an existing pregnancy)
You will be notified upon joining the Scheme of any waiting periods that may apply to you and/or any of your registered dependants.
Bankmed will not apply waiting periods to a member and his/her spouse, partner or child (including a grandchild), on condition that they join the Scheme either:
- From the date on which the member becomes eligible to join the Scheme (i.e. from the member's employment date) or the first of the month following the employment date or
- From the date of the event (or the first of the month following the event) e.g. marriage, birth or adoption, that qualifies the spouse/partner or child to be a dependant on Bankmed
Please note that the above concession applies strictly to a member and his/her spouse, partner or child. It does not include any other dependants who are eligible to join in terms of the rules of the Scheme, irrespective of the date on which they join.
Waiting periods protect medical schemes against anti-selection - anti-selection can occur when someone chooses not to join Bankmed from the first date he/she is eligible to join (and therefore to contribute to the risk pool of the Scheme), but then joins at a later date. The reason for joining may be as a result of a change in his/her health risk profile, with the intention of immediately taking advantage of the Bankmed benefits. The waiting period protects existing members of the Scheme (as the Scheme belongs to its members), who have contributed to the risk pool over time, from such intended anti-selection.