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Deciphering Medical Aid speak

Article provided by Bonitas Medical Fund

If you and your employees join a medical aid, you may find some of the terms used by medical schemes a bit intimidating, confusing or difficult to understand. However, it’s important to know what is being offered the plan you have chosen and the scheme. We asked the Bonitas Medical Fund call centre to share some of the members most frequently asked questions.

Principal member

This is the main member on the medical aid scheme. The principal member pays a larger contribution than any dependants they have registered on the scheme do. Medical schemes refer to principal members (main member) and dependants as beneficiaries.

Medical scheme administrators

Medical scheme administrators are separate entities to the actual medical scheme. The administrator is responsible for managing the administration of the scheme such as processing the claims.

Waiting periods

According to the Medical Schemes Act 131 of 1998, medical aid schemes are entitled to impose waiting periods on new members. This protects other members of the Fund by ensuring that individuals aren’t able to make large claims shortly after joining and then cancelling their membership. Unlike other financial products, medical schemes are not-for-profit entities and are highly regulated to ensure they fulfil a social solidarity role.  There are two types of waiting periods, general waiting periods (up to three months and condition-specific waiting periods (up to 12 months).

During a general waiting period a beneficiary is not entitled to any benefits – in some instances not even Prescribed Minimum Benefits (PMBs). Condition-specific waiting periods are related to a specific medical condition. During this time a beneficiary is not entitled to any benefits for a particular condition for which medical advice, diagnosis, care or treatment was recommended or received.

Late-joiner penalties

In South Africa, medical aid schemes can impose late-joiner penalties on individuals who join a medical aid scheme after the age of 35; those who have never been medical aid members or those who have not belonged to a medical aid scheme for a specified period since April 2001. 

If you are over 35 and haven’t been on a medical aid then – depending on your age – you will be penalised and charged a surcharge between a 25% and up to 75% loading of your premium. This is outlined by the Council for Medical Schemes but at the discretion of the scheme.

Tariffs and rates of payment

Every Medical Schemes has a Rate of Payment – the amount the medical scheme will pay for that service.  Some providers charge different rates known as the Scheme Tariff. Members often misunderstand that 100% of the Scheme tariff/rate doesn’t necessarily mean 100% of the account or what you will be charged.  Read the details of your plan carefully and know what rate is being paid and the benefit limits to avoid any surprises.

Day-to-day limits

Members and their dependants are given a pre-determined maximum amount of money for out-of-hospital expenses during a year. There is a limit to what you can spend after which you move onto the above threshold benefit.

Designated Service Provider (DSP)

A DSP is a healthcare practitioner (doctor, pharmacist, hospital, etc) that is the medical schemes’ choice for members to use.  If you choose not to use the DSP you may have to make a co-payment, which is an additional cost from your own pocket. You can avoid co-payments and get more value for money by using preferred suppliers and DSPs. However, you do not need to go to a DSP in an emergency or if there is none within a reasonable distance.

‘Too often members do not understand what their medical aid option offers and are not familiar with the terminology,’ says Lee Callakoppen, Principal Officer of Bonitas.  ‘The best advice I can offer is to be informed. Take the time to read all the information supplied, if you are unsure phone the scheme and ask questions, or check with your broker. Your health and that of your family is important so it is vital that you are comfortable with the choice you make and are confident your healthcare needs will be taken care of.’

Bonitas Medical Fund is a proud Partner of the NSBC

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