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Medical Aid terms to understand before seeking quotes in South Africa

Article provided by Medshield

Getting medical aid quotes in South Africa is not too hard – most schemes today offer an easy way to access their quoting system. When you do not know what you are being quoted for, however, the process can get a little tricky. Below are some pointers on the ‘glossary of terms’ used: 

Prescribed Minimum Benefits (PMBs)

Every medical aid is required, by law, to provide coverage for certain health conditions. These are called Prescribed Minimum Benefits (PMBs), and they include a list of approximately 25 chronic diseases and 270 conditions.

Medical Aid Savings

Before seeking quotes for any scheme in South Africa, figure out whether or not you wish to have an additional savings account. Medical aid savings are accumulated through a percentage of your annual contributions. This is held in a separate account and members use it to pay for day-to-day expenses.

Specified Tariffs

In South Africa, you will hear language about specified tariffs and the percentage that your medical aid covers. This might confuse members who assume that 100% cover means complete cover. A tariff is what your scheme is willing to cover you for based upon the national Reference Price List, bearing in mind that some specialists and hospitals charge rates much higher than this list.

Premiums

When receiving scheme quotes in South Africa, remember that your premiums are your monthly contributions each month. These are usually fixed, pre-determined amounts.

Principal Member and Dependants

The principal member is the main member responsible for the payment of the monthly contributions. They can also register dependants under their name at additional premiums.

Day-to-Day Benefits

Day-to-day benefits are those that fall outside of In-Hospital treatments. These include visits to doctors, dentists, optometrists, and sometimes medication too. If you regularly need to pay out-of-pocket for such expenses, finding a plan that offers more Day-to-Day benefits is a good idea.

Hospital Plan

Hospital plans are cheaper and offer comprehensive cover for In-Hospital stays and treatments. Most, however, offer little to no cover for Day-to-Day expenses.

Network Cover and Designated Service Providers

Many schemes have a working agreement with certain medical practices and hospitals, which are considered network service providers. Making use of these network service providers means certain procedures are covered at a higher rate and less out-of-pocket or gap payments are necessary.

Waiting Periods

There are two kinds of waiting periods medical aids may impose, namely:

  • A general waiting period: This can take up to three months, wherein a member is not yet entitled to any benefits.
  • A condition-specific waiting period: This period can last anything between 3 to 12 months.

The purpose of these waiting periods is to protect other members in the fund because it means that new members cannot join to make massive claims and then leave soon after.

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