We live in a world of acronyms and industry-specific jargon, which does little to offset the anxiety and confusion of consumers. Understanding your medical aid terms will help you to get the most out of your benefits.
Here's lowdown on terms you need to know.
Principal member
This is the main member on the medical aid scheme. Either one person or someone who has registered one or more dependants.
The principal member pays a larger contribution than the dependants do. Medical schemes refer to principal members and dependants as beneficiaries.
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, they are highly regulated to ensure they fulfil a social solidarity role, ie everyone benefits from the dependence individuals have on each other.
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 of time 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.
Designated Service Provider (DSP)
This refers to a healthcare practitioner (doctor, pharmacist, hospital etc) that has been contracted by your medical aid as the first choice when you need diagnosis or treatment. The scheme generally agrees to pay these providers a specific rate for these services.
Negotiating with healthcare providers is critical to make sure that members get maximum value for money. It also allows us to monitor service to ensure that members receive care and services of the highest quality.
If you choose not to use the DSP, you may have to make a co-payment, which is an addition cost from your own pocket. You do not need to go to a DSP in an emergency or if there is no DSP within reasonable distance.
Acute versus chronic conditions
Acute is severe and sudden in onset and could describe anything from a broken bone to an allergic reaction.
A chronic condition, by contrast is a long-developing syndrome usually lasting more than three months for which you’ll need ongoing treatment, such as diabetes or hypothyroidism. It usually requires life-long treatment and daily medicine to improve quality of life.
Prescribed Minimum Benefits (PMBs)
These are a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected.
The aim is to provide people with continuous care to improve their health and well-being and to make healthcare more affordable.
The Medical Schemes Act requires all medical schemes to pay ‘in full’ for the medical care, pathology, radiology and medication costs related to: The diagnosis, treatment and care of:
- Emergency medical conditions
- A list of 270 medical conditions (known as Diagnosis Treatment Pairs), which includes
- 27 common chronic conditions (defined in the Chronic Disease List)
This means that, by law, your medical scheme has to pay your claims for the diagnosis of and consultations or treatment of a PMB.
Remember, however, that you may be required to inform your medical scheme of your condition to ensure that your treatment is paid for correctly. In addition, schemes may require that you use a specific provider.
Hospital plan
A hospital plan provides you with basic but important medical cover. It covers a range of treatment and procedures when you are admitted into hospital.
All hospital plans, however, have to pay for chronic medication prescribed for the 27 PMB chronic conditions.
Always look at the benefits provided by hospital plans carefully when selecting one, as some offer additional benefits that offer more value for money.
Pre-authorisation
Hospital admissions for non-essential or non-life threatening procedures need to be authorised by your medical aid prior to being admitted. Unless there is a medical emergency, you will have to get pre-authorisation.
If you do not have pre-authorisation, the scheme can refuse to pay. Pre-authorisations are obtained by contacting your scheme administrator at least three days before admission.
Exclusions
Some medical conditions and procedures may be excluded from medical schemes e.g. cosmetic surgery and self-inflicted injuries.
So, get to know your DSPs from your PMBs to ensure you understand what you are covered for and how to get the most out of your medical aid or hospital plan.