Why should I have a medical aid?
In laymen's terms, the purpose of a medical aid is to ensure that you are able to pay for treatment received from either a GP or specialist, or while in hospital. It is very important to "insure" your health. Accidents can happen and you and your family's health are unpredictable.
How to choose the best medical aid for you?
First remember these three points:
- Evaluate you and your dependants' state of health. Your medical needs should be considered first. Also look at your family's medical history.
- Decide what you can afford.
- Evaluate your specific situation on an ongoing basis, as it may change.
Can anyone become a member of a medical aid scheme?
Yes. Medical aids used to be able to reject applicants based on their age or health but it is no longer legal to do so. Cover can be excluded for a period of time e.g. a pregnancy will not be covered if you are already pregnant when you apply.
Will my cover start immediately?
Medical aids are entitled to impose a 3 month general waiting period, during which no claims will be paid, and / or a 12 month exclusion for any pre-existing medical conditions.
Can I belong to more than one medical aid scheme?
No, it is legislated that you may only belong to one medical aid scheme.
Will my employer contribute towards my medical aid premiums?
Employers do not have to subsidise employee’s medical aid premiums but some employers choose to do so.
Can a medical aid scheme terminate my membership?
Yes, your membership can be terminated if your premiums are not paid. If you are on a closed scheme (only available to a specific group of people) your membership will be terminated if you are made redundant or retrenched.
If I terminate my medical aid membership, until when am I covered?
You are covered for treatment that is carried out up to and including the last day of your notice period.
How long do I have to submit claims to the medical aid scheme after treatment?
Claims must be submitted to the scheme within 4 months of the treatment date.
If a member dies, what happens to his dependants?
As long as contributions continue to be paid, the dependants will continue to be covered unless they choose to terminate the membership.
If I am already a scheme member, when should I consider changing options or schemes?
In a rapidly changing environment, ongoing evaluation of your medical scheme has become vital to ensure optimum benefits are available and that you are covered for foreseen and unforeseen medical conditions and emergencies.
Review your own personal needs and basic requirements. Are you still single or have you got married? Do you have children? Have you been diagnosed with a new chronic condition?
What does it mean if my doctor says that he is “contracted out” of medical aid?
When a provider 'contracts out' of medical aids, it simply means that they do not receive payment directly from the medical aid. One of the reasons may be that a doctor charges higher fees than the particular fund prescribes, potentially leaving the patient with a shortfall. It may also be that the medical aid’s claiming procedures or administration process is simply too cumbersome. Another possibility is that the particular medical aid is prescriptive about specific products or medications that these practitioners prescribe for their patients.
What is a Late Joiner Penalty?
The Medical Schemes Act makes provision for schemes to apply a late joiner penalty to members over the age of 35. Depending on the number of years that you have not belonged to a registered South African medical scheme over the age of 35, the late joiner penalty is calculated as a percentage of your monthly contribution and will be added to your monthly contribution.
What is a medical savings account?
A medical savings account is a pool of the member’s own money set aside from the contribution for payment of day-to-day medical expenses (anything that happens outside of a hospital). Any portion that is not used in the year carries forward to the following year and is paid out to the member when he terminates his membership.
What does limited day-to-day cover mean?
In the case of a medical aid with a medical savings account, your out of hospital expenses are limited to the amount of medical savings you contribute. On a capitation plan, your out of hospital expenses are limited to a clearly defined number of visits or monetary amount per benefit.
What is a network option?
These plans make use of a network of hospitals, doctors and dentists that the member must use in order to be covered. This keeps the costs for the medical aid schemes down, which allows the premiums to be cheaper.
What is a comprehensive plan?
A comprehensive plan has a high level of medical savings, hospital cover and chronic medication benefits. They have a benefit that kicks in when the medical savings runs out and claims continue being paid. These are the most expensive options as they have the highest set of benefits.
What is a co-payment?
A co-payment is a portion of the cost of a procedure for which the member is responsible which can be expressed as a Rand amount or a percentage of the total bill.
What is a Designated Service Provider (DSP)?
A group of medical service providers specified in the fund rules from whom services must be obtained to have unlimited and co-payment free benefits.
What are Prescribed Minimum Benefits (PMBs)?
The Medical Schemes Act requires that all medical schemes provide cover for the 26 diseases on the Chronic Disease List on all plan options being:
Addison’s Disease, Asthma, Biploar Mood Disorder, Bronchiectasis, Cardiac Failure, Cardiomyopathy, Chronic Renal Disease, Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, Chron’s Disease, Diabetes Insipidus, Diabetes Mellitus Type 1 & 2, Dysrythmias, Epilepsy, Glaucoma, Haemophilia, HIV / AIDS, Hyperlipidaemia, Hypertension, Hypothyroidism, Multiple Sclerosis, Parkinson’s Disease, Rheumatoid Arthritis, Schizophrenia, Systemic Lupus Erythematosus and Ulcerative Colitis
What is the National Reference Price List (NRPL)?
This is a guide to provide reference prices for all medical procedures and treatments, and is published by the Council for Medical Schemes.
Can schemes refuse to accept new members?
No, not unless it’s is a closed scheme and the member is not entitled to join that particular scheme. In the event of non-disclosure, the scheme may request for immediate termination of membership.
How long is the process of becoming a new member?
This process varies depending on the scheme that the member is applying for (It is best to discuss this information with our Medical aid specialists).
Who qualifies as a dependent?
In order for members to qualify as dependents, they need to be a spouse, child or 100% financially dependent on the main member and be able to prove it if necessary.
When is a child considered dependent considered to be an adult dependent?
Most schemes charge adult rates to children from the age of 21 even if they happen to be full time students but this varies, according to scheme.
If I do not claim from my medical scheme, may I receive a no-claim bonus or rebate?
No, the Act prohibits the payment of bonuses, rebates or refunding of any portion of contributions other than in respect of savings accounts in certain circumstances.
Who should submit the claim?
In most instances, your provider will submit claims directly to the scheme and provide you with a copy for your records. Where providers do not submit to the scheme, it will remain your responsibility. Ultimately, each and every claim remains the responsibility of the member.
What is pre-authorization?
If you or any of your dependants are admitted to hospital, a pre-authorization must be obtained from the scheme. For further information please contact your broker.
How can I terminate my membership?
In order for a membership to be terminated, the member needs to provide the scheme with written notice. It is important for the member to find out exactly what the schemes notice period is. Most schemes require 1 calendar months notice while others require a full 3 months.