Contributions for 2012

The table below shows the total monthly contributions effective from 1 January 2012.
 

Please note that any employer subsidy that may apply to the above contributions may vary, as this is determined by your conditions of employment and administered by your payroll department. Queries in this regard should be directed to your HR department.

PREMIUM PENALTIES FOR PERSONS JOINING LATE IN LIFE

1. Premium penalties may be applied to a late joiner. Such penalties shall be applied only to that portion of the contribution relative to the late joiner and shall not exceed the following bands:

Penalty bands	Maximum penalty
1 - 4 years	0.05 x contribution
5 - 14 years	0.25 x contribution
15 - 24 years	0.50 x contribution
25 + years	0.75 x contribution

For more information about late joiner penalties, please refer to the Society's rules, available from the Society and on the website at www.dbbs.co.za.

The following formula shall be applied to determine the applicable penalty band:

A = B minus (35+C) where:

A = number of years to determine appropriate penalty band
B = age of the late joiner at time of application
C = number of years of creditable coverage which can be demonstrated

2. Should a late joiner penalty already have been imposed and evidence of creditable cover is produced thereafter, the penalty shall be recalculated and such revised penalty shall be applied from the time that such evidence was provided.
3. If an applicant is unable to obtain documentary proof to substantiate periods of creditable coverage, he shall be entitled to produce a sworn affidavit declaring such detailed information and that reasonable efforts to obtain documentary evidence of such periods of creditable coverage were unsuccessful.

DEFINITIONS:

″Child″

• A natural child, stepchild or legally adopted child of a member, or a child who has been placed by a competent authority in the custody of the member or his spouse or partner, or the child born by a member's natural child, or a stepchild or legally adopted child who is registered as a dependant at the time of the birth of such a child.

″Child Dependant″

• A dependent child who is under the age of 26.

"Dependant

• A member's spouse or partner who is not a member, or a registered dependant of a member of another medical scheme; or
• A member's child who is dependent on the member and is not a member, or a registered dependant of a member, of another medical scheme; or
• Someone in the member's immediate family for whom the member is liable for family care and support; or
• The ex-spouse of a member who joined the Society as a result of the transfer of De Beers employees from the Anglo American Corporation Medical Scheme (AACMED) to the Society in 2002, and who was registered as a dependant of this member in terms of the Rules of AACMED at the time.

"Dependent Child"

• a child under the age of 21; or
• A child over the age of 21, but under the age of 26, who is not in receipt of a regular income of more than R2 500 per month; or
• A child over the age of 21 who, due to a mental or physical disability, is dependent upon the member.

″Generic Reference Pricing"

• GRP is a tool used in the healthcare industry to promote the effective utilisation of medicine benefits while ensuring patients have continued access to high quality care. The GRP model calculates the average price of generically equivalent products that have been grouped together (generically equivalent products are those that are identical in terms of active ingredient and strength). This average price is reviewed continuously by a panel of clinical experts to ensure the appropriateness thereof as well as the availability of products contained within this reference price. GRP applies to all medicine where an MCC-approved generic equivalent medicine is available.
• Members claiming for products priced above the generic reference price will be subject to an additional co-payment calculated as the difference between the claimed amount and the reference price. This would be the case even if the doctor indicated on the prescription that the medicine cannot be replaced with a generic equivalent.
• Members should note that the GRP values are updated on a monthly basis and therefore may result in a medicine that was within the GRP limit in one month might exceed it in the next month and therefore attract a co-payment. It is therefore essential to communicate with the pharmacist or operator (in the case of CDM) and ask if there will be any co-payments on the drugs requested. It should be noted that there will be no co-payment on any chronic medicine (provided you have registered your chronic condition with the Society) if you receive it from a DSP and it is within the GRP formulary.

"Late joiner penalties"

• Late joiner penalties may be imposed in specific cases on beneficiaries over the age of 35. Depending on the number of years that they have not belonged to a medical aid, a late joiner penalty will be added to the member's monthly contribution in respect of the beneficiary. It is based on the total number of years the beneficiary has not been a medical aid member since the age of 35 years and is calculated as a percentage of the contribution as shown in the table below. Late joiner penalties will be applied to the contribution applicable to the beneficiary.

″Network Hospital"

• A network hospital is a preferred service provider with which the Society has negotiated specific rates. Please refer to the list of network hospitals at the end of this Guide.

″Pre-authorisation"

• Pre-authorisation means obtaining prior approval for a benefit in terms of the Rules, for example for the provision of chronic medication and the prior approval of any planned admission to a hospital or planned procedures as defined in the benefits table. Pre-authorisation must be obtained not less than 72 hours prior to such admission. This includes an associated treatment or procedure (also dental procedures) performed during hospitalisation. In the case of emergency hospitalisation, the Society must be notified within 24 hours or on the first working day after such an admission or treatment was initiated. In cases where the required pre-authorisation was not obtained, no benefit will apply.

″Scheme Rate"

• The Scheme Rate means the rate at which the Society pays benefits to all service providers for services rendered in network hospitals and selected in-room procedures. The Scheme Rate is limited to 200% above SRPL where these services have been provided in an authorised network hospital and you have received pre-authorisation for any booked procedure. Members will be liable for any amount by which the professional fees exceed 200% of the SRPL. Where a non-network hospital is used voluntarily, the SRPL rate will apply and co-payments are likely to apply. Where certain procedures (for example, circumcisions, vasectomies, colonoscopy's and gastroscopy's) are performed in the doctors rooms in lieu of a hospital admission, these procedures will also be funded at the Scheme Rate.

″Society Reference Price List"

• Benefits are calculated according to the De Beers Benefit Society Reference Price List (SRPL). In cases where service providers charge the SRPL rate, the Society will pay the service provider directly and in full (if there are any co-payments due, these will be collected via the member's salary/pension subject to credit limits). Where service providers charge in excess of 200% of the SRPL, the Society will refund the member the Society's liability and the member will have to settle the account directly with the service provider.

"Waiting period"

• This is a general three-month period after joining the Society during which a beneficiary is not entitled to claim any benefits. This is imposed by the Society in specific cases. In cases where a condition-specific waiting period of 12 months has been imposed, the beneficiary is not entitled to claim any benefits related to the specific condition in question for a period of 12 months.

Note: For more information about late joiner penalties, please refer to the Society's rules, available from the Society and on the website at www.dbbs.co.za

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