What are medical aid benefits?

Benefits means those services rendered by the medical, dental and allied professions, payment for which can be claimed from the Society by its members.

Who can join Cimas?

Cimas has an open membership policy. Membership is available on application from anyone employed in either the formal or informal sector. The bulk of the Society's membership is from the formal sector.

All registrations are effective from the first day of the month of registration.

What do the different terms used in respect of membership mean?

• Member means a person admitted to membership of the Society in terms of its Rules.
• Member Firm means a company, corporate body, special scheme, statutory corporation, partnership, employer or self-employed person which or who contributes as a member firm to the Society.
• Membership Year means the period of 12 months commencing from the first day of the month in which the member or dependant originally joined the Society.
• Pensioner means a member of the Society who has reached Retirement Age and is now categorised under pensioner membership.
• Retirement Age means the age set by the Board, at its sole discretion, from time to time at which a member is deemed to have retired from employment.
• Dependant means a dependent spouse, dependent child, dependent student and/or other dependant.
• Dependent Spouse means the member’s legal husband or wife.
• Dependent Child means the member’s child, stepchild, legally adopted child or child committed to the member’s custody and control by virtue of a Court Order, provided that such a dependent child is under the age of 18 and fully dependent on the member.
• Dependent Student means the member’s dependent child who is over the age of 18 but under the age of 25 and continuing with his or her unbroken education at a recognised educational institution. Such dependent student membership ceases when the dependent student attains the age of 25, unless the Board specifically approves of a continuation beyond that age.
• Other Dependant means such other dependent person as the Board may, in its absolute discretion, decide.

Can membership of a newly born baby be backdated to the child’s date of birth?

Membership of a newly born child may be back-dated to the baby’s date of birth if the relevant application form and contributions are received by the Society on or before the 10th day of the second month following the month in which the child was born.

Newly born babies should ideally be registered on the day of birth to enable the Society to cover any services rendered by the doctor after delivery. If registration is not possible on the day of birth, a completed registration form should be sent to the Society within six weeks of birth. To ensure that the child is not affected by any waiting periods, the joining date should be the first day of the month within which the child was born. This will mean that in‑hospital claims associated with the newborns birth will be covered by the Society.

Why does one sometimes incur shortfalls on claims?

A shortfall might be the result of the fee charged being higher that the tariff awarded. Claims are paid according to tariffs and any fees charged above the tariff award will result in a shortfall. Shortfalls also arise when a member has exhausted the benefit limit for a given membership year. Some benefits are subject to yearly limits, which when exceeded result in a shortfall. Different packages have different limits. Shortfalls can also be due to waiting periods, which mean that the member is not yet eligible to draw funds for certain benefits.

Can one claim the shortfall from Cimas?

No. Shortfalls are not claimable from Cimas but 50% of the shortfall can be claimed as a medical credit from the Zimbabwe Revenue Authority (ZIMRA). When you receive your claim settlement advice from Cimas you submit it with the shortfall receipts to ZIMRA or your Human Resources Department.

How long does it take before claims expire?

Drug claims to be submitted within 2 months from the date of treatment

Medical and dental within 3 months from the date of treatment

Foreign claims within 4 months from the date of treatment

Government and mission hospital claims 6 months from the date of treatment

How does one attain pensioner membership status?

Pensioner membership is available on application for corporate members who have retired from formal employment and have 10 or more years of membership with no break. The pensioner membership application is subject to Cimas Board’s approval. Cut-off age limit is determined by the Cimas Board. Upon the death of such a pensioner, his widow who was a dependent member is eligible to apply for pensioner membership.

What constitutes termination of membership?

• A member or dependant ceases to be a member of the Society:
  1. on his/her death;
  2. on his/her resignation;
  3. if he/she is expelled from the Society; or
  4. if the membership of the member firm or individual under which he/she is registered is terminated in terms of the Society’s Rules and the member has not applied for individual membership.

Under what circumstances may a member be expelled from the Society?

• A member or dependant may be expelled from the Society:
  1. for breach or attempted breach of the Society’s Rules,
  2. for any act attributable to the member which is detrimental to the interests of the Society;
  3. for non-payment of contributions;
  4. for any reason adjudged by the Board as good and sufficient for such action. In such an event the Board will not be obliged to disclose the reasons for its decision.

Can I get my baby Vaccinated at Cimas clinic?

Currently vaccination for babies is done only at our Cimas Bulawayo clinic where the local city council gave us the privileges to do so. In other areas including Harare the city council clinics carries out the mandate. Vaccination is actually a government mandate (it is of national interest) so that is why it is carried out by council and government clinic mainly.

Is there a period of notice required for termination of membership?

Membership of the Society can be terminated on one month’s notice in writing to that effect given by either a member, member firm or the Society.

Why are waiting periods imposed?

Waiting periods are applied for certain benefits in order to safeguard existing members' funds from high treatment costs brought about by new members who join medical aid specifically to access expensive treatment and resign thereafter. This would inevitably drive up claims costs resulting in the Society charging higher contributions. Waiting periods may be applied to any new applicants/dependants.

The waiting periods are applied regardless of whether members have pre-existing conditions or not.

What are the waiting periods?

• The waiting periods are as follows:
• Four months for all new individual members.
  
  Six months for:
  • Specialist treatment
  • MRI, CT scans and Nuclear Medicine
  • Admission or treatment at a hospital
  • Upgrading to a higher package from a lower package. In the event of an upgrade, you continue to enjoy benefits on the lower package while serving the waiting period for the higher package.
  
  
  Nine months for:
  • Maternity benefits
  
  
  One year for:
  • Private Nursing Homes providing constant nursing care
  • Specialist foreign treatment
  • Spectacles or contact lenses (payment for replacements of optical appliances can only be claimed two years after a previous purchase.)
  
  
  Two years for:
  • All internal prosthetic devices
  • Haemodialysis
  • Chemotherapy
  
  
  Four Years for:
  • Orthodontic treatment
  
  
  Waiting periods are also applied when there is a lapse in membership or when a member transfers from another medical aid fund. Newborn babies are not affected by waiting periods, provided they are registered within six weeks from date of birth.

What is your policy regarding upgrades and downgrades?

Upon upgrade from a lower package, members will enjoy benefits after serving the six months waiting periods at the right levels.

Members are only authorized to upgrade or downgrade once within a year.

Is it possible for a member of Cimas to purchase drugs from a pharmacy without paying the pharmacist for them?

It is possible for a Cimas member to purchase drugs without having to make payment to the pharmacist, if the purchase is made from a pharmacy that is on Cimas’s online drug purchase system. This only applies if the purchase price is within the tariff awarded.

In what way is the online drug purchase facility different from the previous facility?

The new facility uses e-claims and is now biometric, essentially members can have their finger prints registered before they purchase drugs. Finger print registration can be done at the point of sale or at any Cimas outlet.

Members can also use the One Time PIN (OTP), which is sent through the member’s cellphone. This PIN is needed to close the purchase.

What does a member need to take to the pharmacy in order to purchase drugs using OTP system?

• There are four items needed. These are:
• 1. Cellphone with the mobile number that has been registered with Cimas
  2. Cimas Membership Card
  3. National Identity Card
  4. Valid Prescription

How is the One Time PIN used for the online drug purchase?

Before you can use the online drug purchase facility, you will need to make sure that your mobile phone number is registered with Cimas. It is to this phone that the PIN will be sent when you are purchasing drugs from a pharmacy that has the online drug purchase facility.

When you seek to purchase drugs from one of the pharmacies on the Cimas online system, you give the pharmacist the prescription and your Cimas card. The pharmacist will log onto the online system and enter your membership number. A one-time PIN will automatically be sent to your cellphone number. The pharmacist will enter the drugs that are being purchased on prescription and their cost. To complete the transaction, you give the pharmacist your one time PIN so he/she can enter it to close the transaction. The PIN is only valid for 10 minutes.

Is it necessary for the member to be present whenever drugs are purchased using the online drug purchase facility? What happens when the member is out of town and a dependant has been prescribed drugs by a doctor?

The member or a dependant of the principal member must be present at the pharmacy, as the pharmacist is expected to verify that the person presenting a membership card is the person whose photograph is on the membership card.

The one time PIN will be sent to the member’s cellphone that is registered with Cimas. If the member is not present at the pharmacy, then he can forward the PIN number to the family member so that it can be given to the pharmacist.

Is there a limit on the number of prescriptions that can be paid for through the online drug purchase facility?

Yes. The on-line drug purchase facility will cover one prescription per month per member. Pre‑authorisation will be required for a second prescription. Members registered with Cimas for chronic medication will be able to access up to five drugs per month. Ordinary members will be limited to three drugs per month. Drugs in excess of these limits will require pre‑authorisation or they can be purchased for cash and a claim be submitted for a refund of the cost.

How is pre-authorisation requested?

The request can be made in person or by e-mail. The prescription must be presented or e‑mailed.

How long does pre-authorisation take?

Normally it takes just a few minutes.

Why are the number of prescriptions and prescribed medications that can be paid for through the on-line drug purchase facility being restricted?

The upgrading of the system has been necessitated by the discovery of extensive fraud in relation to drugs claims paid for through the online system. Such fraud has included non‑prescribed drugs being added to online claims. Limiting the number of drugs and prescriptions that can be paid for through the online system is part of the security measures that have been taken to try to prevent fraudulent claims.

Will Cimas have the capacity to deal with pre-authorisation requests from all over the country?

Yes. Only a few people require medication more than once a month or more drugs than the stipulated maximum number per month. The process does not take more than a few minutes.

Will the one prescription per month restriction and the restriction on the number of drugs that can be claimed through the online system apply to members who visit a Cimas clinic?

No. Drugs prescribed by a doctor at a Cimas clinic can be obtained from the clinic’s pharmacy.

What are the Global Travel Cover requirements?

1. To be applied for by a member who is currently in the country
2. Cut off age is 70 years for both Cimas and non Cimas members
3. Completed Global Travel Cover Form
4. Proof of payment
5. Travel cover is now calculated basing on age multiply by number of travel days and then add $20 set up fee.

What are the Momentum Health requirements?

• Students studying in South Africa can apply for Momentum Health cover.
• New Applicants Requirements
• 1. Completed application form
  2. Proof of payment
  3. Copy of Passport
  4. Copy of acceptance later
• Renewal Requirements
• 1. Renewal form
  2. Proof of payment
  3. Cancellation of Momentum cover
  4. Letter from the school confirming that the child did not enrol
  5. Letter from the student requesting cancellation & banking details
  6. Momentum confirmation cover

What are the requirements for local claims?

• Medical claim
  1. Completed medical claim form
  2. Original receipts
  3. Any other relevant supporting documents
  4. Medical claim form must be submitted within 3 months
  
  
  Drug Claim
  1. Claim form
  2. Copy of prescription
  3. Original receipts
  4. Drug claim forms must be submitted within 2 months
  
  
  Foreign Claims
  1. completed foreign claim form
  2. Receipts
  3. Any other relevant supporting documents
  4. Foreign claims must be submitted within 6 months

Can drugs that have been prescribed by private doctors be obtained from a Cimas clinic?

Yes. It is now possible for members to access drugs prescribed outside the Cimas clinics to be accessed within clinic pharmacies.

Are the restrictions on the use of the online facility not intended to force members to use Cimas healthcare facilities?

No. Cimas healthcare facilities have been established to give members access to affordable health services. However, every member is entitled to be seen by a doctor of his or her choice and to purchase drugs from any pharmacy. Where there is no agreement between a health service provider and Cimas for direct payment, then the member can pay the service provider and lodge a claim with Cimas for a refund of the payment made.

Where the number of medicines or prescriptions exceeds the maximum number ordinarily permitted for payment through the online system, the member can either pay cash and claim a refund or seek pre-authorisation, a process that takes only a few minutes.

What are the requirements for accessing chronic medication?

To access treatment for chronic conditions, members need to register with the Society’s Managed Care department. The Society does not guarantee full cover where a member does not seek pre-authorisation before accessing services.

Will the need for pre-authorisation for prescribed medication in excess of the monthly limit not undermine doctor-patient confidentiality?

No. Respect for confidentiality is one of our core values. Doctors’ claims already include the doctor’s diagnosis of the patient’s condition. This is information that Cimas has and which is always kept confidential. Seeking pre-authorisation does not, therefore, affect confidentiality.

Does Cimas have Foreign Currency pegged products?

Yes, the Society has an option where members/member firms can pay the traditional packages through Nostro Accounts. The Society has also launched new packages which are USD based. For more information, please contact Marketing Department. Payment of the claims is remitted in the currency members pay contributions.

Can we get vaccines at your clinics?

• Babies:
  1. Currently vaccination for babies is done only at our Cimas Bulawayo clinic where the local city council gave us the privileges to do so. In other areas including Harare the city council clinics carries out the mandate. Vaccination is actually a government mandate (it is of national interest) so that is why it is carried out by council and government clinic mainly.
  
  
  Adults:
  1. All other vaccinations are not medically covered except anti-rabies which require the following:
  2. Police Report
  3. Doctor’s letter
  Members must pay cash and submit a claim for a refund.

What are Cimas clinics opening hours and telephone numbers?

Document with details attached.

How often does Cimas pay claims?

The Society pays claims weekly.

What are the iGo requirements?

1. Needs to be a Cimas registered member
2. Complete iGO application form
3. Select gym of choice

What is the waiting period for foreign treatment?

The waiting period for foreign treatment is one year for treatment benefits that have one year or less waiting periods locally, all other waiting periods apply accordingly i.e. haemodialysis and prosthetic benefits accessed outside Zimbabwe should be after two years from joining date.

My doctor has indicated that I need to be treated outside the country – How do I go about it?

Submit to Cimas, a referring letter from the relevant (in terms of illness) local Specialist Doctor who is referring you and the quotation from the Hospital where you will be treated in South Africa. After the treatment has been authorised you will be advised of your authorization number. Please put your member number and contact details on the documents before submitting.

How much do you pay for foreign treatment?

The society reimburses 50% for unauthorized foreign treatment up to the package’s foreign treatment limit for such and usually 70% for authorized foreign treatment limit up to the package’s limit for such. (Refer to below table for package’s limits).

I have been referred to India for treatment how can Cimas help me?

Please come in to our offices with the following documents x-rays, MRI scans and reports as well as a letter from your Doctor explaining the nature of your condition, ask to see someone from the Foreign Department.

Do you cover airfares and accommodation for treatment outside the country?

No medical treatment costs only.

How do you refund me after l purchase my drugs outside the country where they are cheaper?

The refund will be at 75% of cost up to your local drug limit.

I was treated outside the country three months ago. Can I submit my claims?

Yes, foreign claims are valid six months from date of treatment.

Do you cover IVF treatment?

Yes, it is covered, member has to bring in a quotation for authorisation.

Can I use my Cimas card outside the country?

• Cimas packages are local packages, hence the card cannot be used outside the country.
  
  NOTE:
  1. Primary and Basicare packages do not access foreign treatment
  2. Healthguard Deluxe foreign treatment (outside Sub Saharan region) – benefits not available.

I am / my so and so is going to be admitted into hospital how much do you pay, how much are the shortfalls?

We pay 100% of the stipulated prices for members on private, MedExec and Healthguard Deluxe packages, private hospitals however hiked their fees in May 2014 by 5% we absorbed 2.5% so there is always a 2.5% shortfall on most of the charges. On possible shortfalls amount, it is best to consult the hospital as they have the claiming rules and rates and they know what they are likely going to use on you during admission and how the medical aid pays.

I was admitted at Avenues Clinic (just an example) they asked me to pay a shortfall. What is the shortfall for?

It is best to check with the hospital what the payment they are asking you to pay is for. However (applies to Avenues only) if you were seen in the hospital’s casualty and subsequently admitted its likely that the shortfall is for casualty consultation as it is a rule that a service provider cannot charged for both casualty consultation and admission on the same day at the same institution.

Shortfalls may also be from per rule non claimable items – these the hospital can best explain to you- these shortfalls will also reflect on your monthly statement when the hospital submits your claim.

I received a settlement advice slip showing that l have a shortfall at the hospital after my admission?

Please verify with the hospital before you come to the Cimas offices, if the shortfall is for a non-claimable item it is non- refundable. Or (Agent can check what the shortfall is for as it may be an error on the provider’s side or Cimas’s side that is claim held up for error 51 –report, or stale period- verify if its genuinely stale per claim submission period durations.

My daughter was treated at the emergency unit and now they phoned me to say Cimas have shortfalled my claim, what is the shortfall for?

• There are 2 likely possibilities:
  1. Three emergency visits allowed per year, per member, are exhausted.
  2. Non emergency cases, claimed as emergency consultations by the hospital, but paid as non emergency consultations code (02291).