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What is Medical Aid?

Medical aid is an insurance type plan you join - and pay a monthly contribution or premium - to get help when paying costs of medical treatment.

It helps you to pay for the best hospitalisation, chronic illness and day-to-day treatment you may need and to do that quickly!
No one can be refused membership.

Fear of Using Government Hospitals

hospitalWould you really feel safe and secure - having to use a state hospital?
Do they offer the best care?

Yes, there are fine medical providers in the government healthcare system, but overall the state of care is appalling and it is your health that is at risk!


Public healthcare is more affordable than private, but state hospitals are not always free!
If you are employed and earning more than R70 000 a year, you will have to pay some or all of the costs of your care.

Private healthcare is an alternative. But, private healthcare costs and arm and a leg!

Unless you have a large resource of easily available money, you many not be able to get the best medical treatment you need!

The ONLY way to get ensure that you will get the finest private medical care (immediately in an emergency), is through a medical aid.

There are around 21 medical schemes in South Africa and that you can investigate and consider joining.
However, not all schemes are the same and differ widely in benefits, administration and solvency.

It is highly recommended you seek the help of medical aid professionals like ourselves, who can guide you in the right direction when you investigate plans to join, as there is a lot you need to be aware of before you decide on a scheme.

As a medical aid member, you do have certain enforceable rights according to the Medical Schemes Act. Please see Council for Medical Schemes



How does a Medical Aid Work?

what is medical aid

Medical aids are regulated through the Medical Schemes Act, which is enforced through the Council for Medical Schemes.

This is a statutory body established to provide regulatory supervision of private health financing, through medical scheme.

Their vision is to: "Promote vibrant and affordable healthcare cover for all", and they achieve this by:

  • protecting the public and informing them about their rights, obligations and other matters, in respect of medical schemes;
  • ensuring that complaints raised by members of the public are handled appropriately and speedily;
  • ensuring that all entities conducting the business of medical schemes, and other regulated entities, comply with the Act to ensure the improved management and governance of medical schemes;
  • advising the Minister of Health of appropriate regulatory and policy interventions that will assist in attaining national health policy objectives; and
  • ensuring collaboration with other entities in executing our regulatory mandate
  • setting out a complaints procedure for people who have a complaint against a medical scheme

  • Medical schemes are non-profit companies, managed by a board of trustees who are elected by the members. They are responsible for managing the scheme for the benefit of those members.

    Schemes exist only for the benefit of their members and funds are used for administration and claims.
    This helps to ensure that every member benefits from cross-subsidisation - where the healthy support the sick.

    Schemes must hold 25% of every member's annual contribution in in a reserve fund.

    This adds security for members, ensuring that there are always funds for claims.

    There are "open medical aid schemes," which anyone can join and "closed schemes," specifically designed for employees of companies.

    Premiums are also carefully regulated.

    Everyone pays the same premium for their plan, regardless of their age or health. A scheme cannot "load" a member's contribution, other than by way of a Late Joiner Penalty.



    Waiting Periods

    waiting periodA medical scheme may impose waiting periods after underwriting your application.

    You need to accept them before a plan will begin.

    A 3 Month General Waiting Period - where they may not pay anything at all or they may pay for certain Prescribed Minimum Benefits (PMBs).
    This general waiting period will be imposed:

  • if you have not been a member of a South African medical scheme for the past 90 days or longer, before applying for membership.
  • if you voluntarily change medical schemes and have not been on your previous scheme for a period of 2 years or more.
  • You must pay contributions during waiting periods.

    A pre-existing condition waiting period of up to 12 months, where nothing for that condition will be paid during the period. Thereafter, you have full access to the plan's benefits.

    Waiting periods are there to protect the other members of the scheme from new members making large claims upon joining, having them paid and then leaving the scheme (called anti-selection.)

    Waiting periods do not apply to:

    1. Prescribed minimum benefits (PMBs) other than those specified.
    2. A child dependant born during the period of membership.
    3. A member moving between benefit options, unless there is a remaining period of previously imposed waiting periods still to complete.
    4. An involuntarily transfer to another scheme, due to a change of employment.
    5. Where an employer changes the medical scheme with effect from the beginning of the financial year.


    Late Joiner Penalties

    New applicants older than 35 need to prove they have had past membership or a monthly Late Joiner Penalty is imposed. The penalty is added to your monthly contribution indefinitely and is determined by this table:

    No. of years applicant was not a member of a medical aid since age 35Penalty%
    1 – 4 years1.05 X contribution 5%
    5 – 14 years1.25 X contribution25%
    15 – 24 years;1.5 X contribution50%
    25+ years1.75 X contribution75%

    As you can see, it is important you make the effort to identify (and prove) all your past medical aid membership.

    You do this by providing current membership certificates or an affidavit attesting to the membership.



    How a Medical Scheme Pays Claims.

    The monthly premium you pay, is pooled and it is from this collective fund that claims for medical expenses are paid. A medical aid plan pays claims either:
  • from the scheme itself - risk cover (insurance portion) – usually for major events and hospitalisation or,

  • a member's day-to-day savings – for doctor’s visits, blood tests and medication.
    When these funds are spent, you need to pay for costs - except on higher plans which may offer a safety net when savings are used.
  • what is medical aid

    What a medical scheme pays for from risk versus savings is an important issue.

    Some schemes extend the risk benefits to out of hospital claims (like emergency room trauma, a broken leg or stitches). Your day-to-day savings account then lasts much longer!

    Other schemes have an extended trauma benefit, where ongoing physiotherapy is paid.

    Some also pay for MRIs and pregnancy scans - not your savings!

    THERE IS EVEN A SCHEME THAT PAYS ESSENTAL DENTAL COSTS, WITHOUT USING YOUR SAVINGS!

    Another scheme offers a unique day-to-day savings option, where you only start paying for savings once you use them!

    Most schemes charge you for savings from the start - whether you use them or not!
    So, by default, these premiums are lower, until you start using the savings!

    (Please see sections below for details on risk and savings benefits.)

    claimsWhat are 100% or 200% of medical aid rates?

    At the beginning of the year, medical schemes meet with providers to determine a basic rate for services.

    But, private providers can charge any fee (often up to 500% of scheme rates) as long as patients feel they are getting value for that price.

    A list of recommended tariffs (Reference Price List or RPL) for specific in hospital treatments and procedures exists and medical aids generally pay up to 5% more than these published tariffs.

    These are the Medical Scheme Rates.

    Schemes use claims experience and the amount of funds they have, to work out percentage payouts for scheme rates.

    Lower cost plans usually pay 100% of scheme rate for hospitalisation. Other (more expensive) plans pay 200% to 300% of these rates.

    Plans with linked (network) providers can pay cost in full, irrespective of these scheme rates.

    It is a difficult exercise to balance the value of these rates, as the pool of funds they have, is finite - made up of member contributions and other investments.
    If they overpay for certain procedures, then the solvency and overall claims playability of the medical aid scheme can be affected. If they underpay members are likely to resign and join other schemes!

    So, medical aid rates are based on what members can really afford and not what providers may charge.

    In an attempt to control the ever-increasing cost of medical aid, many schemes are also introducing co-payments for certain services, hospitalisation, MRI and CT scans, specialised dentistry etc.

    A co-payment is an amount you pay when having one of these treatments or procedures.

    You are strongly advised to consider a GAP or TOP UP insurance plan to address both these threats.

    This separate insurance plan will cover most in-hospital claim shortfalls and scheme co-payments.

    By adding a Top Up plan you can improve your medical aid benefits, so-much-so, that you can even consider joining a lower cost/benefit plan - with a lower premium - and still have an excellent, no risk medical aid for virtually the same premium as the higher medical aid!



    Prescribed Minimum Benefits (PMB's)

    Medical Aids must ensure that you have access to certain minimum health services, irrespective of the type of plan you join. They must pay for the diagnosis, treatment and care of:
  • any emergency medical condition;

  • a limited set of 270 medical conditions (defined in the Diagnosis Treatment Pairs);

  • and 25 chronic conditions (defined in the Chronic Disease List).
  • A scheme can require you to use only listed medicines and certain Service Providers (Networks) when covering PMB conditions.

    (Please note that Prescribed Minimum Benefits may be refused during the waiting period, if you have never belonged to a scheme or did not belong to a scheme for at least 90 days before you applied for new membership).



    Chronic medicines

    chronicIn terms of the PMB guidelines, schemes have to pay for 25 PMB chronic conditions.

    The costs for the diagnosis, treatment and care of these listed conditions, no matter what medical aid plan you are on.

    If you have a chronic need, outside of these PMB conditions, you may need to look at a plan with higher chronic benefits to get cover.

    Every plan has a list of medicines - called a formulary - which they provide. Certain schemes also allow for medicines not on that list, but you will get a co-payment if you use them.

    The scheme may also require you to use a designated provider.

    You must make sure you register for chronic benefits or the scheme will use your savings to pay for chronic medicines!

    Schemes offer specific care programmes to help members live with certain chronic illnesses like HIV, Oncology, Diabetes, Cardio and Mental Health. You register for a programme and then have access to additional, relevant benefits that may be offered.

    We can help you if you have any concerns.



    Cancer Benefits

    Most schemes offer a separate benefit for oncology.

    Some plans only pay for PMB-related cancer treatments and others have a limited amount for non-PMB care.

    Plans may offer unlimited benefits, but have a co-payment after as specified limit is used.

    Lastly, there are plans that have unlimited oncology, but only from network providers.

    Most schemes apply Independent Clinical Oncology Network protocols. ICON is a organisation of oncology specialists and offers management and treatment for oncology patients.

    A few plans offer benefits for specialised oncology medicines, but those plans are very expensive.



    Preventative care benefits.

    chronicSchemes offer a range of preventative care benefits in order for you detect (and then treat) medical conditions early. By doing this you will get the best care as soon as possible.

    Benefits such as ‘flu injections, blood glucose and pressure tests, mammograms, Pap smears and prostate screenings, all paid for by the scheme and not from your savings!
    Some even offer child growth assessments and milestone tracking!

    You may have to use network providers but, can get a range of benefits such as GP, dental and screening benefits paid.

    You should investigate the value of these benefits, as they will aid in preventing more serious (and costly) conditions developing in years to come!



    What Medical aid terms mean...

    Your very first step is to understand what the various medical aid terms mean.
    This is critical to your understanding of what you are buying.

    Because there are so many, there is a separate page listing Medical Aid Terms.



    Risk and Savings of a Medical Aid

    There are 2 main area of funding in a medical aid.

    Risk pool - Part of your contribution goes into this funding pool. It is designed to pay claims for all members of that plan.

    This allows for cross-subsidisaton - where members at higher risk of having to claim, are subsidised by those with lower claims risks.

    The size of the fund gives an idea of future of claims, allowing the scheme to spread the risk they face, hopefully allowing for lower premiums and making that plan more affordable for you and I.

    Savings pool - If you have a plan with savings, then up to 25% of your premium goes into this fund to help you pay day-to-day healthcare costs.

    The scheme will advance you (interest-free) up to a year's worth of these savings at the beginning of each calendar year. You can only use these funds to pay medical costs (not co-payments) and you cannot "top up" a fund when savings are used up.
    You can roll over any balance at year-end.

    Because it is your money, there is no cross-subsidisation allowed and once your savings are used, you either pay further costs yourself (the self-payment gap), have access to additional benefits or use a threshold benefit, which the more expensive plans have.

    The threshold benefits pays once your savings are used and your claims have added up to a pre-defined amount.

    (However, some plans do offer a limited cross-subsidisation with savings being placed into a "community type fund". If you do not use your annual amount in such a fund, you lose it.)

    These funds are yours to help pay for nearly all your medical costs - except PMB's.

    Plans can pay certain day-to-day costs from the risk portion of a medical aid, thus extending the buying-power of your savings.

    This plan pays Dental costs from Risk!

    bestmedicalaid.co.za can help you identify and join one of the top medical aids in South Africa!

    Get your FREE quote now!

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    Last update: November 16, 2019

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