What is Medical Aid!

A guide answering all your questions about what Medical Aid offers, its benefits and how it works!

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 aid – 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 aid must be your priority!

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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 aid, the lower any possible penalty will be. You can never be too young and healthy to join!

How does medical aid work?

There are basically 2 forms of medical cover

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 this runs out 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!

What does a Medical Plan Do for Me?

Comprehensive cover
If anyone in your immediate or extended family (grandparents, parents, uncles, aunts, or siblings) suffers from hereditary chronic diseases - like high blood pressure, high cholesterol or diabetes - you need to plan for that happening to you.Your out of hospital and chronic medicine costs may well dictate that you look at a comprehensive plan.
If you have existing or are expecting future health issues – that are NOT PMB conditions - then a comprehensive plan may be what you need, as these plans offer both in and out of hospital cover.

hospitalIf the answer to this question is a resounding NO – then why not consider a hospital only plan and pay your own day-to-day costs?
It will certainly be way more affordable, whilst protection you against the real threat of not having a medical aid - hospitalisation!

Hospital cover
You want unlimited private hospitalisation (maybe with a few sub-limits for some treatments) and guaranteed hospital admission with emergency cover.
You want to make sure that major surgeries and medical treatments in hospital are covered.

These plans are specifically designed to cover the major portion of all treatment and accommodation costs that may arise during hospitalisation in a private clinic or hospital.Some treatments require an upfront payment, (for example back surgery, gastroscopies, laparoscopies, removal of wisdom teeth, colonoscopies and joint replacements), however you are covered for major medical emergencies and hospitalisation.

Day-to-day (out of hospital cover)Treatments like doctors, dentists, and over the counter medication. These costs are generally paid from a savings account you have in the medical aid. As long as there are funds in the account, you can pay bills.

Once the funds are used, some plans pay further, limited, benefits (like network GP consultations or medicines).
Other plans offer a safety net where, once your claims add up to a defined amount, they then pay further costs (sometimes with a co-payment from you) for the rest of that year.
But, these are expensive plans!

Day -to-day benefits is an area where you may be able to “save“ on your medical aid.
We have never experienced anyone going bankrupt over a GP,chemist, dentist or optician’s bill, so the risk of self-funding these expenses should be low.
Maybe you should consider a hospital ONLY plan and pay your day-to-day costs yourself?

Medical aid is an insurance, that covers you for large and unexpected events which could financially wipe you out, not a way to buy chemist supplements and occasional GP visits!

You can 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.

You can also invest in a dental plan to help with dental these costs. They will probably be your highest day-to-day expense going forward.

Consider a GAP or TOP UP plan to help you pay these costs. These are totally separate products to a medical aid and will work with any medical aid. Remember, if your medical aid would not have paid for that claim, neither will the Top Up.

Chronic medicines. All medical aid plans have to offer cover for 26 PMB conditions. If you have a non-PMB chronic condition, you may need to look at a plan with higher chronic benefits. All plans have lists of medicines they provide.
Again, you may need a higher benefit plan if you have a need for a specific chronic medicine.
We can help you with these concerns.

You also have to make sure how the scheme and option cover oncology, dialysis and HIV. Most schemes have specific benefit programmes for these conditions, which offer good cover, but 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.

Network plans are very popular because they are affordable.

These plans are aimed at the lower income person, family and pensioners who want to ensure that they will have access to private hospitalisation and out of hospital healthcare when needed.Also for those who cannot afford full medical aid, or can only afford a basic hospital plan, but still wants some peace of mind concerning private hospital benefits and day-to-day care.
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 R370 pm for as single member.

HOW TO JOIN THE BEST MEDICAL AID



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Is medical aid necessary?

Without medical aid, you have to deal with poor medical service and treatment. You can very easily incur high medical bills. And poor treatment could easily prolongs your illness, again making it more expensive to fully treat.
It is clearly better to get cover in order to get the best medical treatment and service and to get your life back to normal as quickly as possible.

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peter pyburn brokerpeter pyburnemailpyburn@peterpyburn.co.za


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