With 18 open medical schemes and hundreds of plan options to choose from, making a decision can be overwhelming. It’s also that time of year when medical aid members are able to make changes to their plan options for the upcoming year. It is important that this decision is made wisely as it can have a large financial impact. 

Before a successful decision can be made regarding the best medical aid scheme for your needs, understanding the industry-specific jargon and terminology is key. In this article we unpack some of the terms you will need to understand in order to select the right plan. 

Important Medical Aid Terminology

Hospital plan: Covers you for medical procedures that are performed in a private hospital, whether you are in an accident and need an emergency operation or have a planned procedure. Cover for medical attention given outside of a hospital, like seeing your GP, visiting the dentist or getting new glasses at the optometrist, is not covered by a hospital plan. Depending on the option you choose, you could be covered between 100% to 300% of medical aid rates and if there are financial shortfalls, these can be covered by supplementing your Hospital plan with Gap Cover.

Something to note: Whilst the casualty ward is attached to the hospital building, it does not mean that you have been admitted into hospital. For example, if you needed stitches and were treated in the casualty ward, chances are that this would not be covered under your hospital plan. 

Medical Savings Account: The Medical Savings Account (MSA) is an amount that is provided to you at the start of the year. You can use this money to pay for day-to-day medical costs like doctor visits, X-rays and dentist visits. Any money in your MSA that you haven’t used by the end of the year is carried over to the next year.

(Your MSA is what would cover your stitches in Casualty)

Threshold benefit: Generally provided by comprehensive medical aid plans, a threshold benefit is risk cover which kicks in after you have depleted your Medical Savings Account. In most cases, there is a self-payment gap during which members have to fund their own medical aid expenses before the threshold benefit kicks in.

Medical Aid: A traditional medical aid is the combination of a hospital plan and an MSA. The higher priced and more comprehensive options could include a threshold benefit.

Gap Cover: Provides shortfall cover where doctors and specialists charge above medical aid rates of cover. Gap cover works in conjunction with your medical aid. 

Prescribed Minimum Benefit (PMB): All medical scheme benefit options are required to offer members a minimum level of benefits as set out in the Medical Schemes Act. These include the 270 DTPs (diagnosed and treatment pairs), as well as the 26 chronic diseases (CDL’s).

Designated service provider (DSP): This can be a doctor, a pharmacist, a hospital, or any other registered healthcare provider that is the first choice of your medical scheme. Where members choose to use a non-DSP, they may be required to pay a co-payment or a penalty.

Co-payment: A portion of the cost for which the medical scheme member is responsible.

Chronic condition: A chronic condition is a human health condition or disease that is persistent or otherwise long-lasting in its effects or a disease that comes with time. The term chronic is often applied when the course of the disease lasts for more than three months. 

Exclusions: Some medical conditions and procedures may be excluded from medical schemes as part of the design of the medical scheme. Traditionally, these would have included cosmetic surgery and self-inflicted injuries.

Waiting periods: A medical scheme is permitted to apply waiting periods to certain categories of applicants to protect themselves from those who only join medical schemes when they become ill. There are two types of waiting periods: general waiting periods which are normally only three months, and condition-specific waiting periods which are normally 12 months.

Late Joiner: An applicant or dependent of an applicant who, on the date of the application, is 35 years or older. Medical schemes are entitled to charge higher premiums. These premiums could be increased by up to 75% and the unfortunate part of a late joiner penalty is not a once off penalty, it is attached to your monthly premiums going forward.

Community rating: This refers to the requirement that medical scheme contributions may only be differentiated on income and family size for a benefit option and so all members with the same income band (where applicable) and family size are charged the same, regardless of other factors such as age or health status

Navigating the jargon attached to medical aid options is difficult in itself. To ensure that you make the correct option choice, please feel free to reach out to our team here. They will be able to dive deeper into the benefits of each option and ensure that you are covered correctly for 2022.