What is Medical Aid!

A guide answering all your questions about what Medical Plans offer, their benefits and how they work!

Why you need a Medical Aid

medical aid pillsPoor public healthcare is the reason South African’s need reliable and affordable help with medical costs. Government hospitals are not an attractive option. However, private healthcare is expensive, so to get that care, you need a medical aid. Private hospitals provide higher standards of care and equipment for advanced diagnostic and other technologies. Nursing and medical are generally better qualified and so command higher salaries. This results in high costs for long term hospitalisation or care for serious injuries, surgery, or chronic illnesses.
It costs over R 8,500 per night for a premature baby neonatal private hospital stay (and some stay for 5 months) - bed only - no consultations, medicine or medical supplies!

With no medical scheme cover – or at the very least a hospital only plan - you will be in serious trouble!
Medical cover is probably the most important safety net you can buy for yourself and your family.
Joining a medical plan must be your priority!

Why you must join a Medical Scheme NOW!

medical aidYou can have a car accident the very next time you travel! You can suffer a survivable heart attack whilst reading this!
How much do you think 6-weeks in intensive care will cost?
Do you have that money to spend?

Waiting periods can be imposed on a new members, the length of which depends your health and how long you’ve been without medical aid cover.
They can range from a 3-month general waiting period to a 12-month condition-specific waiting period.

There are also Monthly Late Joiner Penalties to consider. The older you are when joining a medical scheme, the more severe the late joiner penalty.
The penalty depends on how many past years of medical aid membership you have.

So, the sooner you join a medical scheme, the lower any possible penalty will be. You can never be too young and healthy to join a scheme!


How does medical aid work?

There are 2 forms of medical cover:
Comprehensive (expensive) medical scheme cover that pays hospital as well as day-to-day costs, or
Hospital plan (cheaper) that will pay in-hospital expenses only. You pay all out of hospital expenses like GP, dentist, chemist and optical yourself.

Your medical scheme pays claims out of either:
the scheme itself - risk cover – usually for major events. This is the insurance portion of the scheme or
day-to-day savings – for doctor’s visits, blood tests and medication. When these are spent, you no longer have cover for day-to-day expenses, except on the higher plans which offer a safety net when savings are used.

What a medical scheme pays for from risk versus savings is an important issue.
Some schemes have extended the cover that is paid from risk not your day-to-day savings, thus extending the life of your savings!
For example, emergency room trauma like a broken leg or stitches, arel paid claims without using your day-to-day savings account.
Some medical aids have extended this trauma benefit further, where ongoing physiotherapy is paid.
They also pay for MRIs and pregnancy scans from the scheme and not your savings!

Provide your own day-to-day savings fund...open a bank savings account, or use your home as an access bond – pay extra into it and use that for day-to-day expenses.
We also sell a HealthCard – a dedicated debit card that can only be used for your medical expenses. An ideal way to fund for your day-to-day expenses.

Chronic medicines have to be paid for 26 PMB chronic conditions.
All plans have lists of medicines they provide. If you have chronic need, outside of these PMB conditions, you may need to look at a plan with higher chronic benefits.
We can help you with these concerns.

Most medical schemes have specific benefit programmes for oncology, dialysis and HIV. It is important to make sure exactly what that cover is.

Preventative care benefits. Most medical schemes nowadays offer a range of preventative care benefits in order for you to remain healthy.
Benefits such as ‘flu injections, mammograms and prostate screenings, all paid for by the scheme in full.
You use network providers, but can get a range of benefits such as GP, dental and screening benefits paid, either with a hospital only, or a more comprehensive plan.
Investigate the value of the preventative care benefits, as these will aid in preventing more serious conditions developing in years to come.

What will a Medical Plan Do for Me?

If there is a history of hereditary chronic disease in your family - like high blood pressure, cholesterol or diabetes - you may well have to consider a comprehensive plan.
If you have existing or are expecting future health issues – that are NOT PMB conditions - then agin, a comprehensive plan may be best for you.

If you are healthy then consider a hospital only plan and pay your own day-to-day costs.
They are more affordable, whilst protecting you against the real threat of not having a medical aid - hospitalisation!
Some even pay out of hospital dental costs!

Medical aid is an insurance, that covers you for large and unexpected events which could financially ruin you.
It allows you to access the best treatment when you do need it and that cannot be under estimated!


Top Up/Gap cover plan

medical aidAt the beginning of a year all medical providers and medical aids decide on the value of a procedure. That is known as the scheme (medical aid) rate.
Medical aids then start paying at 100%, 200% or 300% of that rate. Generally hospital and ward fees are charged at the scheme rate and are fully covered.
Private providers, they can charge up to 500% (5 times) medical aid rate. This is referred to as the private rate.
So, if you use private providers, you will have a shortfall from your medical aid claim and it is vital you take out Top Up/Gap insurance to meet this threat!
These are totally separate products to a medical aid and will work with any medical aid.

Increasingly medical schems are also adding procedure co-payments and a Top Up plan should also pay for those procedure co-payments.

medical aid

Dental Insurance

Out of hospital dental costs can be extremely expensive.
Most medical aids have poor dental benefits and many members consider the DENTAL PLAN to help with dental these costs.

Network plans are very popular because they are affordable.

These plans are aimed at the lower income person, family and pensioners who want access to private hospitalisation and out of hospital healthcare

They are recommended for families with small children and high needs for doctor or dentist visits. Offering comprehensive cover for emergencies at selected private hospitals, they generally do not cover hospital admissions for more elective procedures such as, for example, elective caesarean, specialised dental and nasal surgery. The premiums are based on income, so those earning less get to enjoy the same benefits as those with higher salaries. Premiums start from a little as R 839pm for as single member.


medical scheme
MedBioWorld:one of the largest Internet sites for medical and biotechnology journals, associations, databases and other resources.

peter pyburn brokerpeter pyburnemailpyburn@peterpyburn.co.za


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