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24/04/2021

Understanding Medical Aid

Understanding and having either a Medical Aid or Hospital Plan in South Africa will end up saving you a lot of money during any kind of medical crisis. These plans are paid monthly for various medical expenses. What do you get? What you paying for? We will highlight the main differences with some explanations and guidelines.

Medical aid schemes are actually non-profit organisations, where individuals contribute and access money needed to pay for various medical expenses. This monthly amount that members pay is called a premium or contribution which is administered by the scheme.

Medical Aid or Hospital Plan?

hospital plan covers you for medical procedures that are performed in a private hospital, such as if you’re in an accident and need an emergency operation. If you need cover for medical attention given outside of a hospital, like seeing your GP, visiting the dentist or getting new glasses at the optometrist, a hospital plan would not cover these costs – however a medical aid plan would subject to savings and benefits.

Due to this distinction, hospital plans are much cheaper than full medical aid plans because you get less coverage.

A hospital plan requires you to pay a monthly premium that would then cover you for treatments and procedures as an in-patient in a private hospital. Any medication or doctor visits out of hospital would be for your own account. If you need to go into hospital for a planned procedure, you would need to get authorisation from your hospital plan provider beforehand, except in an emergency, then the hospital would normally arrange your admission directly with the provider.

Most medical aid plans provide both in-hospital and out-of-hospital cover, depending on which option you choose. So you’ll be covered for all the things a hospital plan covers you for, plus day-to-day medical care, such as going to the doctor and dentist. Depending on your plan though, your day-to-day savings (called your Medical Savings Account or MSA) are limited up to a certain point. So, make sure you do your research before signing up to a medical aid plan ensuring the limits will be enough for you and your family.

Income-based Plans - You get Medical Aids and Hospitals based on this. Low-cost medical aid for which contributions are based on the member's monthly income.

Understanding the Jargon

On a medical aid or hospital plan you will frequently see several terms used.

Risk - This section of your premium is the highest and is based on what it says, the "risk" of ending up in hospital. Should you choose a Hospital Plan Only - this is the only portion you would pay.

MSA - Medical Savings Account - savings account held by a medical scheme that allocates funds to members to be used for the payment of qualifying medical expenses.

OHEB - Out of Hospital Expense Benefit or Day-to-Day Benefits - again, these are benefits that you get for out of hospital. As above the level of benefits is determined by your medical scheme option.

DSP - Designated Service Provider - A network of healthcare professionals with whom a medical aid scheme has pre-negotiated rates. Depending on the plans they've chosen, a medical aid scheme may require members to use only designated healthcare providers or to pay co-payments if they use other providers.

NHRPL - National Health Reference Price List - A set of baseline tariffs designed by the Council of Medical Schemes (CMS). It serves as a rates guideline for healthcare practitioners and medical aid schemes.

ICD-10 codes - A globally accepted disease classification and coding system that identifies diagnoses, symptoms and procedures. Medical aid schemes use the codes to determine what benefits a member is eligible for and how these benefits must be paid.

SPG - Self Payment Gap - On higher medical aid plans, once your savings are exhausted, you enter the self payment gap, whereby you pay for certain medical expenses out of your own pocket, as per your option chosen until you reach your ATB.

ATB - Above Threshold Benefit. Once you have entered your ATB, certain out of hospital benefits are once again paid for my your medical aid, up to a set limit as per your option. Always check what your SPG is when choosing your option.

Network - Most Medical aid schemes usually have their own network of hospitals and other healthcare providers that they prefer you to use if you want full cover, so it’s important to see where those networks fall within your area.

Gap Cover is short-term insurance policy which provides shortfall cover where doctors and specialists charge above medical aid rates of cover. Gap cover works in conjunction with your medical aid.

There are so many options out there to suit your budget and daily needs. Before you sign up, make sure that you have read through all the important documents provided so that you protect your loved ones from any potential illness or injury. Deal with a good Broker who can give you several options with easy to understand comparisons and that you are getting the cover you expect.

FREE Quote for Medical Aid versus Hospital Plan

Learn More about Medical Aid & Hospital plan Companies

The Council for Medical Schemes (CMS) Consumer Assistance Help

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