Frequently Asked Questions
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 is unpredictable. If you cannot afford comprehensive cover, at least a basic hospital plan is recommended.
What is a Medical Savings Account?
The Medical Savings Account is an amount you get at the beginning of the year or when you join Medical scheme. You pay back this amount monthly as part of your medical scheme contribution. This will pay for day-to-day medical expenses like GP visits, radiology and pathology from the Medical Savings Account, as long as you have money available. Any money remaining in the Medical Savings Account at the end of the year will carry over to the next year.
If you leave the Medical Scheme or downgrade your health plan before the year is up, you will owe Medical Scheme the portion of the Medical Savings Account you have used but have not yet paid back
How long do I have to submit a claim?
You must send us your claim within four months from the date you saw your healthcare professional.
What do i do in an emergency?
In an emergency, go straight to hospital. If you need medically equipped transport, call The medical aid emergency number . This line is managed by highly qualified emergency personnel who will send air or road emergency evacuation transport to you, depending on which is most appropriate. Remember that you, a loved one or the hospital must let us know about your admission as soon as possible
How do I get a copy of my tax certificate?
Medical Scheme members who need a copy of their tax certificate can get a copy from us by sending a request to firstname.lastname@example.org
What is gap cover, and do I need it if I already have medical aid cover?
Gap cover is a form of short-term insurance that covers potential shortfalls between the cost of medical procedures in hospital and the percentage that your medical aid pays towards these costs. For example, some medical practitioners charge up to 400% of MSR rates. If your medical aid only covers 100% of MSR rates, then a shortfall of 300% will be payable by you. Gap cover will cover this outstanding amount. Although gap cover does not cover out-of-hospital procedures,
Which is the most affordable medical aid plan?
Generally, hospital plans are the most affordable types of medical aid, as they do not offer any day-to-day benefits. But bear in mind that the most affordable medical aid plan may not be the most appropriate one for you. In most cases, hospital plans are ideal for young, healthy members who do not have any dependants, and whose medical requirements are minimal. However, members with young children (who may require frequent paediatric check ups, vaccinations, medication, etc.), as well as individuals with chronic ailments or medical conditions may find it more affordable to take out a medical aid plan that also offers day-to-day benefits.
Also remember these three points:
What is a Capitation Plan (Network Option)?
These plans provide individuals with basic day-to-day cover at affordable rates, at specific network providers. Network providers differ from scheme to scheme and members have to use designated service providers.
*Please note that some of the schemes have income categories. This means that what you pay every month for the plan is dependent on what you earn.
From how many medical aids can I choose?
In 2008, there were 119 registered medical schemes, of which 37 were open schemes . By the end of 2009, the number of open schemes had decreased to 34. Within open medical schemes one can choose from around 177 different plans. The largest open medical schemes in South Africa are the following (in alphabetical order):
What is the main difference between medical aids?
The main differences between different medical aids, and options within them, is the cover provided with regard to specialists and other suppliers while you are in hospital.The Department of Health has published specific rules and tariffs for specific health services and procedures performed in or out of hospital. These tariffs for the Council for Medical Schemes are called the National Health Reference Price List or NHRPL. They are only a guideline for specialists and anaesthetists to follow when they charge you for a specific procedure performed in hospital. Most medical providers charge a far higher fee than this rate.
The scheme rate to which many quotes and brochures refer is usually slightly higher than the NHRPL rate – about 2% - 5% more, depending on the scheme. This means that, should the specialist or anaesthetist charge you 300%, he is actually charging you three times more than the guide price.
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?
Do penalties generally apply if I leave a scheme or switch?
Most schemes require written notice of between a month and three months of your intention to resign from the scheme.Changing options within your current scheme can be done only towards the end of the year, for commencement on 1 January. Schemes have their own rules with regard to changing options during the year.
There are two kinds of waiting periods, namely:
The Medical Schemes Act (No 131 of 1998) came into effect on 1 January 2001. In terms of this Act:
Source : medicalaid.co.za
Medical scheme terms
1. Principal member
This is the main member on the fund. It can be a single person, or someone who has registered one or more dependants on the scheme. The principal member often pays a larger contribution than the dependants do. If the main member dies, the dependants can usually stay on the fund, but one of them will have to become the new principal member.
2. Open and closed funds
An open fund is open to everyone who wants to join. A closed fund is usually just for certain groups of people, such as the employees of a specific company, for whom membership of the fund is often a condition of employment. Members of the public cannot join these medical schemes.
3. Medical scheme tariff
This is the specified tariff in rand that the medical scheme will pay for certain procedures or consultations. Your specialist may charge R750, but if the medical fund tariff on your option is only R500 for that particular type of consultation, you will have to pay the difference. This is called a co-payment.
4. Waiting period
When you join a medical scheme you cannot claim for day-to-day expenses during the first three months, unless you have come straight from another medical scheme. But you are covered for medical emergencies from the day you join. You can be excluded for no more than 12 months for the treatment of a pre-existing condition.
5. Prescribed minimum benefit (PMB)
There are 270 conditions for which all members have to be treated, according to the Medical Schemes Act. All medical schemes and hospital plans are bound by this law. But hospital cash-back plans and health insurance products are not, as they are not governed by the act.
6. Day-to-day benefits
These are out-of-hospital benefits, which differ greatly from scheme to scheme and from option to option. The bigger your contribution, generally the bigger your cover. These benefits can cover things such as GP visits, prescription medication, dental treatment and visits to the optician. Check your benefit schedule for your particular option.
7. Hospital plan
This is usually cheaper than a comprehensive plan and covers you for hospitalisation only, and not for out-of-hospital treatment. All hospital plans, however, have to pay for chronic medication prescribed for one of the 27 chronic conditions named in the act.
8. Medical savings account (MSA)
A percentage of your contribution (usually 15% to 25%) is paid into this savings account, from which your day-to-day claims are paid. If you do not use this money in a given year, it is transferred into your MSA for the following year. If you leave the fund and you have money in your MSA, it will be paid out to you.
9. Chronic illness benefit
There are 27 chronic conditions specified by the act. Your medical scheme must pay for this medication on an ongoing basis. You can be required to use generics. Once you have registered your condition as a chronic one with your scheme, this medication will not be paid for from your MSA, but from your overall limit.
10. Acute medicine benefit
These are once-off prescriptions, such as an antibiotic for an ear infection. When the infection clears up, you no longer need to take the medication, unlike medication for something such as high blood pressure, which usually has to be taken for life.
11. Network doctors/network hospitals/designated service providers
A scheme might have a working agreement with certain doctors, hospitals or service providers to treat its members at the medical scheme tariff. A scheme may require its members to use these services, and can expect them to make co-payments, should they choose to use out-of-network services.
Unless there is a medical emergency, you will have to get pre-authorisation from your fund before you will be admitted to a hospital for specific procedures. If you do not have pre-authorisation, the scheme can refuse to pay. Pre-authorisations are obtained by contacting your scheme administrator at least three days before admission.
13. Self-payment gap
If you have R5 000 for the year in your MSA and it is depleted, you go into the self-payment gap where you have to fund day-to-day medical costs yourself. If that is R3 000, for example, once you have reached it, you could claim what is called above-threshold benefits. This is usually also limited to a rand amount.
14. Clinical protocols
These are considered to be medically appropriate claims for certain conditions and procedures put together by teams of medical professionals. Your cover is subject to the scheme’s rules and funding guidelines.
15. Overall annual limit
This is often a set amount (but not always) which includes a combined limit of in- and out-of-hospital expenses.
16. Ex-gratia payment
If your benefits for certain things have run out, you can put in a request for payment of further treatment. Each case is carefully considered and judged according to certain guidelines. No scheme is obliged to grant all requests for ex-gratia payments.
References: council for Medical Schemes and Nasmed Benefit Brochure
Source : Finance 24