Having medical aid is a luxury many people simply cannot live without. However, making sense of the jargon when choosing a medical aid is challenging, leaving many consumers with very little knowledge of what they’re actually paying for and, more importantly, what the medical aid will cover.
We’ve put together a list of some basic terms that you should look out for when deciding on a medical aid option, and we help you to make sense of the great medical aid maze.
PRESCRIBED MINIMUM BENEFITS
Prescribed Minimum Benefits – or PMBs – is a set of medical conditions and services that all medical aids must pay for, regardless of which option you are on. PMBs are set out, in detail, under the Medical Schemes Act which stipulates that your medical aid must pay for the diagnosis, treatment and care of any of the following:
- EMERGENCY MEDICAL CONDITIONS
This includes any sudden and unexpected onset of a health condition which requires immediate medical attention and/or an operation. In order to be deemed an Emergency Medical Condition, you must prove that, should you not have received the given medical treatment, you would have suffered serious and permanent physical damage or death.
- CHRONIC CONDITIONS
There are a total of 25 chronic conditions that must be paid for by your medical aid. This includes medication, doctors’ consultations and any relevant medical tests. However, the medical aid can limit cover for these conditions to only a specified list of medications and treatments. This list is known as the Standard Treatment and Essential Medicines List.
The 25 chronic conditions covered by all medical aids (regardless of the option you’re on) are:
- Addison’s Disease
- Cardiac Failure
- Chronic Obstructive Pulmonary Disorder
- Coronary Artery Disease
- Chronic Renal Disease
- Crohn’s Disease
- Diabetes Insipidus
- Diabetes Mellitus Types 1 and 2
- Multiple Sclerosis
- Parkinson’s Disease
- Rheumatoid Arthritis
- Systemic Lupus Erythematosus
- Ulcerative Colitis
- Bipolar Mood Disorder
- 270 MEDICAL CONDITIONS
A further 270 medical conditions are listed under the Diagnosis and Treatment Pairs (DTPs) under the Medical Schemes Act. This list includes a diagnosis along with the way this diagnosis should be treated and what medication should be prescribed. Should your diagnosis and/or prescribed medication and/or treatment not be listed here, it will not be covered by your medical aid. However, you can request your doctor submit a motivation as to why your medical aid should cover the prescribed medication and/or treatment.
You can download the full list of Diagnosis and Treatment Pairs here.
** ADDITIONAL DISEASE LIST: Some medical aids offer cover for diseases not listed under the PMBs. Talk to your medical aid to find out more about whether they have an additional disease list and, if so, what’s included on this list.
These benefits depend on your plan and could cover any services that happen more frequently such as dentistry, optometry, doctor’s visits and medication (excluding those listed under PMBs). Day-to-day benefits also extend to most specialist services such as physiotherapists, ear, throat and nose specialists, sonars and X-rays, pathology and any other services that are used for non-emergency reasons.
MEDICAL SAVINGS ACCOUNT (MSA)
Your stipulated day-to-day benefits are covered by your savings. The total savings amount is made up of a ***percentage of your monthly contribution. Let’s say your medical aid decides that 20% of your monthly contribution will go towards your savings, and you pay R3000 per month, your MSA will look like this:
- 20% of R3000 = R600 p/m
- R600 x 12 months = R7200
This means you will have R7200 to spend on all day-to-day benefits. Once the money in your MSA runs out, you will have to pay for any day-to-day benefits out of your own pocket.
***The percentage is determined by your medical aid, so make sure you ask them about this before you decide on an option.
DESIGNATED SERVICE PROVIDER (DSP)
This list is made up of healthcare providers and facilities including doctors, dentists, hospitals and clinics that are covered should such needs be related to a PMB condition.
Should you choose to make use of a healthcare provider or service not listed on your option, you will have to pay a portion or all of the bill yourself.
You can ask your medical aid for a list of Designated Service Providers (DSP) in your area. Should they not have a provider within a reasonable distance from where you live, you can then go to the provider of your choice and the medical aid is obliged to cover the costs. This same rule applies when the DSP is unable to provide the medical care needed within a reasonable time.
MEDICAL AID RATE (MAR)
When going through your medical aid option booklet, it’s important to also check the MAR for the various medical procedures and equipment – this is how much the medical aid will pay for the specified service. The MAR is based on the Reference Price List which provides the recommended tariffs for specific treatments and procedures. It’s important to understand what the indicated MAR means. There are three rates – 100%, 200% and 300% of of the MAR. Let’s use the following example to explain exactly how the MAR impacts your budget.
You have to undergo an operation on your foot. Your medical aid’s MAR is set at R30 000 for the procedure. However, the procedure will cost R92 000 altogether.
- 100% of the MAR: this does NOT mean your medical aid will pay the full amount. Instead, your medical aid will only pay R30 000. You are responsible for paying the other R60 000.
- 200% of the MAR: the medical aid will pay R60 000 towards the final bill, leaving you with R30 000 to pay out of your own pocket.
- 300% of the MAR: the medical aid pays R90 000 for the procedure, leaving you with R2000 to pay.
Sadly, many healthcare providers charge up to 500% or 600% of the MAR rate, still leaving medical aid members with a big amount to pay themselves (aka a co-payment).
Speak to your medical aid before any planned medical procedure to see whether you can reduce the co-payment. You can also speak to the medical service provider to negotiate a possible discount. However, this must be done in advance.
Sources: Council for Medical Schemes | Department of Health | SA Government