Frequently Asked Questions – Medical Aid & Insurance
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Frequently Asked Questions:
How do I decide which medical aid scheme to join?
Informed Healthcare Solutions (IHS) has been in the medical aid industry for 25+ years and we deal with all the major medical aid schemes. We only recommend established schemes with a good Global Credit Rating (claims paying ability).
How do I decide which medical aid option to join?
IHS will assist you to evaluate your needs in terms of extent of hospital cover and day-to-day benefits, chronic medication and what premium you can afford to pay. Quotes for the appropriate options are generated on a spreadsheet for easy comparison.
Which is the best medical aid in terms of credit rating?
Global Credit Rating (GCR) is an independent company that rates the claims paying ability of medical aid schemes with AA being the highest rating and BBB- the lowest.
|Discovery Health Medical Scheme |
Bonitas Medical Aid Fund
Liberty Medical Scheme
Pro Sano Medical Scheme
Sizwe Medical Fund
Resolution Health Medical Scheme
Advisors assessment, September 2008
Which is the best medical aid in South Africa according to Specialists?
In a recent survey, medical specialists rated Fedhealth in the top three medical schemes they would recommend, with the other two being closed schemes. The schemes were rated on the level of interference with the doctor-patient relationship, balanced billing, efficiency with accounting and pre-authorisation, co-payments, rate fixing, reversals and formularies.
How much will it cost me to use a medical aid broker (intermediary)?
Some medical aid brokers are fee based but IHS does not charge employer groups or individual members a service fee. Your premium is the same as if you had contacted the medical aid scheme directly.
What happens if I have a claim problem?
If you are unsuccessful in resolving claims problems with the medical aid scheme directly, IHS will assist you to resolve the query.
What if I have questions about completing the application form?
IHS is one of a dwindling number of advisors who call on clients to assist in completing application forms and explaining benefits to new members.
Can anyone become a member of a medical aid scheme?
Yes, provided they can afford the monthly premium. Medical aids used to be able to reject applicants based on their age or health but it is no longer legal to do so. Cover can be excluded for a period of time e.g. a pregnancy will not be covered if you are already pregnant when you apply.
Will my cover start immediately?
Medical aids are entitled to impose a 3 month general waiting period, during which no claims will be paid, and / or a 12 month exclusion for any pre-existing medical conditions.
Can I belong to more than one medical aid scheme?
No, it is legislated that you may only belong to one medical aid scheme.
Who qualifies as a dependant on a medical aid scheme?
Anyone who is financially dependent on the member may be included on their medical aid.
Will my employer contribute towards my medical aid premiums?
Employers do not have to subsidise employee’s medical aid premiums but some employers choose to do so.
Can a medical aid scheme terminate my membership?
Yes, your membership can be terminated if your premiums are not paid. If you are on a closed scheme (only available to a specific group of people) your membership will be terminated if you are made redundant or retrenched.
If I terminate my medical aid membership, until when am I covered?
You are covered for treatment that is carried out up to and including the last day of your notice period.
How long do I have to submit claims to the medical aid scheme after treatment?
Claims must be submitted to the scheme within 4 months of the treatment date.
If a member dies, what happens to his dependants?
As long as contributions continued to be paid, the dependants will continue to be covered unless they choose to terminate the membership.
What does it mean if my doctor says that he is “contracted out” of medical aid?
When a provider ‘contracts out’ of medical aids, it simply means that they do not receive payment directly from the medical aid. One of the reasons may be that a doctor charges higher fees than the particular fund prescribes, potentially leaving the patient with a shortfall. It may also be that the medical aid’s claiming procedures or administration process is simply too cumbersome. Another possibility is that the particular medical aid is prescriptive about specific products or medications that these practitioners prescribe for their patients.
What is a Late Joiner Penalty?
The Medical Schemes Act makes provision for schemes to apply a late joiner penalty to members over the age of 35. Depending on the number of years that you have not belonged to a registered South African medical scheme over the age of 35, the late joiner penalty is calculated as a percentage of your monthly contribution and will be added to your monthly contribution.
What is a medical savings account?
A medical savings account is a pool of the member’s own money set aside from the contribution for payment of day-to-day medical expenses (anything that happens outside of a hospital). Any portion that is not used in the year carries forward to the following year and is paid out to the member when he terminates his membership.
What does limited day-to-day cover mean?
In the case of a medical aid with a medical savings account, your out of hospital expenses are limited to the amount of medical savings you contribute. On a capitation plan, your out of hospital expenses are limited to a clearly defined number of visits or monetary amount per benefit.
What is a network option?
These plans make use of a network of hospitals, doctors and dentists that the member must use in order to be covered. This keeps the costs for the medical aid schemes down, which allows the premiums to be cheaper.
What is a comprehensive plan?
A comprehensive plan has a high level of medical savings, hospital cover and chronic medication benefits. They have a benefit that kicks in when the medical savings runs out and claims continue being paid. These are the most expensive options as they have the highest set of benefits.
What is a co-payment?
A co-payment is a portion of the cost of a procedure for which the member is responsible which can be expressed as a Rand amount or a percentage of the total bill.
What is a Designated Service Provider (DSP)?
A group of medical service providers specified in the fund rules from whom services must be obtained to have unlimited and co-payment free benefits.
What are Prescribed Minimum Benefits (PMBs)?
The Medical Schemes Act requires that all medical schemes provide cover for the 26 diseases on the Chronic Disease List on all plan options being:
Addison’s Disease, Asthma, Biploar Mood Disorder, Bronchiectasis, Cardiac Failure, Cardiomyopathy, Chronic Renal Disease, Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, Chron’s Disease, Diabetes Insipidus, Diabetes Mellitus Type 1 & 2, Dysrythmias, Epilepsy, Glaucoma, Haemophilia, HIV / AIDS, Hyperlipidaemia, Hypertension, Hypothyroidism, Multiple Sclerosis, Parkinson’s Disease, Rheumatoid Arthritis, Schizophrenia, Systemic Lupus Erythematosus and Ulcerative Colitis
What is the National Reference Price List (NRPL)?
This is a guide to provide reference prices for all medical procedures and treatments, and is published by the Council for Medical Schemes.
Any suggestions...? We look forward to hearing from you.
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