Medical aid is a necessary yet expensive purchase in South Africa. Due to the public healthcare system unable to cope with the public demand, people who can afford it or who work for larger employers will choose private healthcare. They buy medical scheme products to cover such healthcare expenses.
Since medical aid is expensive, it is important for a member to understand its benefits, in order to make the best use of it when needed. As each new year begins medical aid members start with a clean slate, with new benefits and replenished savings available. If you manage your medical expenses correctly you can avoid out-of-pocket expenses and limit the possibility of running out of benefits. 1. Read up on your medical aid plan Take the responsibility of understanding your medical aid plan. Visit the medical scheme's website, find your specific medical aid plan information and read through it. Check out the FAQs. If your medical scheme creates YouTube videos on your specific plan and benefits, watch these videos. The more you understand your medical aid plan, the better you are in a position of making use of benefits provided for by the plan. 2. Speak to your Healthcare Advisor Medical aid plans are complex. A medical aid plan has many details, terms and conditions. Many members will struggle to make sense of it. A Healthcare Advisor with suitable qualification, training and years of experience can simplify matters for you and answer your specific questions. 3. Find a GP on your medical aid's network Using network doctors is an invaluable tool to make your medical aid last longer as it means you won’t be charged more than a specific amount. 4. Always use partner networks Medical schemes negotiate preferential rates with providers who have partnered with them. This means if you use a network hospital, doctor or pharmacy you will not be charged more than the rate agreed with the scheme. This will also help you to avoid co-payments, deductibles and additional out-of-pocket expenses. 5. Ask your pharmacist Buy over-the-counter medicine to treat less serious ailments and consider using generic medicine which is cheaper but effective. Pharmacists are able to provide sound medical advice on problems such as rashes, colds or illnesses that are not severe, simply ask! 6. Going to hospital - get the facts Talk to your doctor or specialist before being admitted to hospital. Check what they are going to be charging and what your scheme will cover. If there is a large difference, don’t be afraid to approach your doctor to see if they are prepared to adjust their fee. Alternatively, you can also check if there are other healthcare providers who are on your scheme’s network that will charge you a better rate. 7. Remember to pre-authorise Pre-authorisation is required for all hospital admissions to ensure your stay will be covered. Always ask if there are any co-payments or sub-limits that will apply and what you can do to avoid these. For planned procedures, it’s also worth checking with your scheme if you will obtain better cover by using contracted providers or having the procedure performed in the doctor’s rooms or a day clinic. 8. ICD-10 codes If you need to undergo an operation, ask your surgeon for the codes that will be charged. This will include the procedure codes and those for any other products that will be needed, this all helps with pre-authorisation and ensuring the costs will be covered. 9. Chronic health conditions Some schemes offer programmes to help you manage severe chronic conditions such as cancer, diabetes and HIV/AIDS. These programmes are usually covered from the risk portion of your medical contribution and are not funded from your savings account. They help you use your benefits to maximum advantage while ensuring you receive quality care by using specific providers. With thanks to: www.w24.co.za
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What are prescribed minimum benefits? (PMBs) Prescribed Minimum Benefits (PMBs) are a set of pre-defined conditions that all medical schemes in South Africa have to cover, by law. They form part of the Medical Schemes Act, with the aim being to ensure that the wellbeing and health of South African medical aid members is safeguarded and that healthcare is more affordable. The existence of PMBs means that anyone who is part of a medical scheme, no matter what plan they’re on, can receive treatment for 270 hospital-based and 25 chronic conditions and that the cost of these will be covered in full. PMBs also cover any kind of emergency treatment and include certain out-of-hospital treatments. How does a doctor decide if my condition will be covered by a PMB? Your doctor will look purely at your symptoms to decide on this, making the decision diagnosis-based. They won’t look at how the condition was contracted in the first place, but rather the symptoms you are displaying at that current point in time. They will then decide where you should receive the treatment, either in the doctor’s rooms or in-hospital. What kind of conditions does it cover? You can read the full list of hospital-based conditions covered, which are grouped into 15 broad categories and include things like heart attacks, strokes and pneumonia. The 25 chronic diseases in the PMBs include conditions like epilepsy and bipolar mood disorder – read the full list. Where can I get help with a PMB related issue? The Council for Medical Schemes (CMS) was established to supervise medical schemes in South Africa and exists to protect your rights as a consumer to be treated fairly. If you need help with a PMB issue, contact them for guidance. Source: Fedhealth To see if your condition qualifies for PMB cover please contact Namhla in our Health Department email health@daberistic.com , tel (011)658 -1333 Source: Fedhealth If you’ve been diagnosed with a disease lasting more than three months which is a chronic condition and you then need ongoing treatment. If the medication falls within your medical aid's chronic disease list, you then will be able to use your benefit for chronic medication. Below is a few question answered from the Council of Medical schemes which regulates medical schemes. Is my medical scheme obliged by law to provide cover for certain medical conditions? Yes, these are known as Prescribed Minimum Benefits (PMBs). They were introduced into the Medical Schemes Act to ensure that beneficiaries of medical schemes would not run out of benefits for certain conditions and find themselves forced to go to State hospitals for treatment. These PMBs cover a wide range of ±270 conditions, such as meningitis, various cancers, menopausal management, cardiac treatment and many others, including medical emergencies. However, take note that certain limitations could apply, such as the use of a Designated Service Provider and specified treatment standards. PMB diagnosis, treatment and care are not limited to hospitals. Treatment can be received wherever it is most appropriate, including a clinic, outpatient setting or even at home. Always check your benefits with your medical scheme and make sure you have the scheme's rules at your disposal. Is it true that schemes now also have to provide chronic medication? Yes, the list of PMBs includes 25 common chronic diseases in the Chronic Disease List (CDL) and other chronic conditions within the ±270 Diagnosis Treatment Pair (DTP) section. Medical schemes have to provide cover for the diagnosis, treatment and care of these diseases. However, you should remember that a medical scheme does not have to pay for diagnostic tests that establish that you are not suffering from a PMB condition. The treatment algorithms (guidelines for appropriate treatment) for each of the CDL chronic conditions have been published in the Government Gazette while the chronic diseases in the DTP section are guided by the public sector protocols. This assures you of good quality treatment and reassures your medical scheme that it will not have to pay for unnecessary treatment. Your doctor should know and understand most of the guidelines so that he or she can help you get the treatment you need for any of these conditions without incurring costs that your scheme does not cover. Why are some chronic illnesses covered and some not? The diseases that have been chosen are the most common, they are life-threatening, and are those for which cost-effective treatment would sustain and improve the quality of the member's life. Does my scheme need to do anything to ensure that the Designated Service Provider can treat me? The Council for Medical Schemes has been advising medical schemes to enter into contracts with any DSP they choose, especially State hospitals, to ensure that these providers can supply the necessary services. Many State hospitals have set up separate wards to serve beneficiaries whose treatment and hospital stay is paid for by their medical scheme and to whom the hospital can then afford to provide better service. Other schemes have made arrangements with private hospital and certain retail pharmacies to treat their beneficiaries. Can I be refused cover for the chronic conditions if I do not get authorisation or have certain tests? Yes, medical schemes can make a benefit conditional on you obtaining pre-authorisation or joining a benefit management programme. These programmes are aimed at educating members about the nature of their disease and equipping them to manage it in a way that keeps them as healthy as possible. For example, many schemes offer treatment through groups that manage diseases such as diabetes, and are equipped to give the medication and monitor that disease. To register for your Chronic medication please contact Namhla in our Health Department email health@daberistic.com , tel (011)658 -1333 Source: Council for Medical Schemes |
AuthorKevin Yeh Archives
January 2025
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