Choosing the best medical aid for your needs is one of the most important decisions you need to take. The choice affects not only the level of your healthcare, but also has huge financial implications for you and your family.

Choosing the correct plan is a fine balance between your healthcare needs, your affordability and your risk aversion level. Since all three of these inputs are so personal to your individual situation, we cannot recommend a blanket “best” plan.

Although we have tried to simplify information as much a we can, we have not been able to avoid some of the necessary jargon, and we do not have full insight into how the schemes operate.

Forums

To add to the transparency, we have introduced Forums to the website, and we encourage you to participate. By offering you a forum for your own experience with a healthcare funding issue, and the specific scheme, we hope to add even more transparency to the healthcare system, as well as more accountability. We encourage you to participate and read the forums. You can find out more here.

Scheme Rate

This is the foundation block of how schemes pay for claims. Every healthcare “line item” has an IDC code, and each scheme sets the maximum price it will pay for that code. If your healthcare provider charges more than this scheme rate, you will have to pay the difference out of pocket.

There are two main exceptions to this:

• Some schemes pay at “200% scheme rate” or “300% scheme rate” on some plans. That means they those plans will pay a multiple of their basic scheme rate to the healthcare provider, thus minimising your out-of-pocket expenses.
• Some schemes guarantee that they will cover the healthcare cots of provider if the providers are part of the scheme’s network, or if the providers have a payment arrangement with the scheme. The actual rate the provider then charges is irrelevant to you

Lastly, if your plan offers an above threshold benefit, it is very likely that claims accumulate to the threshold at 100% scheme tariff only, regardless of the actual cost claimed.

PMBs

The medical aid sector is governed by the Medical Aid Schemes Act, and that Act directs medical aid schemes to pay for the diagnosis and treatment of 270 conditions according to certain guidelines, and without charging you the end user directly for the treatment.

In other words, when you get treated for any of the 270 conditions, the schemes have to cover your costs without asking you for a co-payment, and without using your medical aid savings.

These 270 conditions, known a Prescribed Minimum Benefits (PMBs) cause much problems and confusion, for schemes, healthcare providers and for you.

We are committed to using this website to offer as much transparency to PMBs as possible, while also pointing out their pitfalls. You can find a list of the PMBs here, a collection of all our PMB content here,and more general info on PMBs here.

Update: The government has indicated that it will re-look at the PMB legislation, and will implement changes as soon as March 2017.

Here is what you need to know now, applicable for now:

• The 270 conditions cover all life threatening conditions, as well as most cancers and other degenerative conditions.
• As a medical aid member, you are guaranteed in hospital and out of hospital treatment for these conditions.
• Only “treatable” cancers are considered PMBs. Read more here.
• Schemes can prescribe where you receive treatment for PMBs, and most have Designated Service Providers (DSPs) to offer this service. If you choose to not use a DSP for a PMB, you might be liable for extra costs, as schemes are not obligated to covers costs above those charged by the DSP. This is a very important caveat, since a lot of schemes/plan designate state hospitals as DSPs. Therefore, you might think you have coverage for private hospitals, but in fact if you are treated for a PMB you might be relegated to a state hospital, or have to co-pay for a private hospital treatment. You can read more about DSPs here.
• The Act pairs each PMB with the minimum treatment that must be covered by the scheme. Unfortunately, in most cases, this treatment is simply described under a blanket description of “Managed care”. In very simple terms, what this mostly means is that the scheme has to pay for the treatment that a public hospital would offer to a non-scheme member who suffered from the same condition.
  It is reasonable to assume that as a scheme paying member, you might want better, more advanced treatment. Be aware that this might cost you out-of-pocket. For more specific information on this, read about the obligations medical aid schemes have re PMBs.
• The good news is that you have to be offered treatment, including out-of-hospital treatment, for all PMB conditions, no matter what plan you are on. That means that if you are financially constrained, you can rest easy knowing that even the cheapest plans guarantee coverage and out-of-hospital treatment for many conditions that would otherwise be affordable to you.
• The bad news is that PMB coverage requires careful ongoing management from you the scheme member. You have to be very vigilant that you are getting the coverage that is due to you, that you are not co-paying, and that you are using the DSPs. There is more information on this on our website under each scheme, and you can also read all our PMB content here.

Types of plans

Hospital plans: these cover in-hospital costs only, as well as out-of-hospital costs for any approved PMB conditions (see above). Some schemes may offer some extra benefits like preventative care, standard dentistry etc.

Savings: some plans set aside a portion of your premium toward out-of-hospital or day-to-day costs. You usually get the full years value of the extra premiums available in January. Savings cannot be used by scheme to fund PMB benefits prescribed by law.

“Extended Funds”: Different schemes have different names for these, but essentially it is a “budget” that schemes allocate to you for day-to-day expenses.

Comprehensive plans: These plans usually offer a savings account (see above), and once that is depleted might force you to pay for out-of-hospital expenses out of pocket (self payment gap). However, after a while, when all the day-to-day claims that have been paid (either by scheme or by you) accumulate to a certain amount, the scheme starts paying all further claims once again. This is called “above threshold benefit”. Some plans limit this benefit, and some plans have it as unlimited, with sub-limits for various benefits. See more here.

Income based plans: Some plans are income based plans, which means that the premiums you pay as a member are adjusted on a sliding scale according to your income. The less you make, the less you pay. Schemes define “income” according to own rules, so check with the scheme.

Managed care

All schemes have managed care programs, which you need to join if you want to get the full benefits available for certain conditions. By joining such a program, you will most likely be assigned a case manager to help you manage your condition, get you the care that you need and ease the claim process.

The post How medical aids work appeared first on Medical Aid Bible.

A late joiner penalty is a permanent penalty, added as a percentage of the base premium (not the savings portion). It is meant to dissuade or penalise people from not belonging to a medical aid in their youth, when they are presumably healthy, and joining only when they get older, and are a bigger drain on the schemes.

Therefore, members who apply for medical aid coverage and are over 35 years old may have to pay a Late Joiner Penalty.

How is it calculated?

It’s a three step process:

• First we count out how many years it has been since you turned 35. (If you are under 35, the penalty band will not apply to you) (A)
• Then we work out how many years you have spent on a medical aid since you turned 21. (B)
• We then work out (A) -(B) to calculate your penalty band.

Penalty Band = (Current Age – 35) – (Years of credible medical aid coverage)

You then apply the Penalty Band to the table below:

Examples:

• You are 43 years old, and were a member of a medical aid for 5 years, (22-27 yrs old):
  Penalty Band = (43 – 35) – (5) = 3 years = 5% penalty
• You are 55 years old and were a member of two medical aid schemes in the past. One for 6 years (23-29 yrs) and one for 15 years (32-47yrs)
  Penalty Band= (55 – 35) – (6 + 15) = -1 = No penalty

Note:

• The late joiner penalty is calculated as a percentage of the basic premium (not the savings portion).
• Credible medical coverage is defined as belonging to a recognised medical aid scheme. If you cannot prove your past membership and have taken all reasonable steps to try and obtain proof, you can submit an affidavit outlining your past membership, and this has to be accepted by the scheme.
• According to the Medical Act, if a penalty has been applied incorrectly in the past, it cannot be claimed back. However, we feel that if this was due to an error on the part of the scheme, you should discuss it with them, or the Medical Scheme Council.
• Membership of an overseas medical aid does not count when working out the “years of credible coverage”.
• Late joiner penalties follow members, even if they change schemes.
• Schemes are flexible on this, and each have their own discretion on how/whether they apply the late joiner fee. Speak to them and negotiate!

We have come across a number of schemes who misrepresent how a Late Joiner Penalty is calculated, in their favor. Our explanation is taken directly from the Medical Schemes Act. Please let us know if your scheme works out the late joiner penalty differently from our formula below.

The post Will I have to pay a Late Joiner Penalty? appeared first on Medical Aid Bible.

How much does a medical aid broker cost?

A broker does not cost you, the member, anything. Your premiums do not increase if you have a broker, and the scheme pays the broker directly.

The Medical Aid Act dictates the maximum amount that a broker can be paid: 3% of the premium, or R81, whichever is lower. This is a monthly payment that the broker receives from the scheme.

What are the advantages of having a medical aid broker?

A good broker will become familiar with your personal medical needs, and will advise you accordingly on the best plan for you. He or she can also liaison with the schemes on your behalf, and can explain benefits to you clearly.

Brokers contract to certain medical aids only. We have not come across any broker who represents all the schemes. That means that even if a broker is very familiar with your personal medical needs, he might not represent the scheme that is best suited for your needs. A broker might also be swayed by financial incentives from the schemes when recommending a plan to you.

It is always in your best interests to put the responsibility of your healthcare in your own hands, and to get assistance and support directly from the scheme or from a broker if you have one.

The post Do I need a medical aid broker? appeared first on Medical Aid Bible.

Some schemes will have an appointed person who deals with escalated queries or complaints. If your complaint is not resolved to your satisfaction, ask your scheme if the matter can be escalated.

You can also contact the Council of Medical Schemes. This is “a statutory body established by the Medical Schemes Act to provide regulatory supervision of private health financing through medical schemes”.

The Council regulates all schemes, and you can submit a complaint to them at any time. Put all your communication in writing, and ensure that you submit all relevant information, including copies of all correspondence between you and your scheme. You can send this by registered post, or you can email it to [email protected].

You can also visit the Council of Medical Scheme’s website, or call them on 0861 123 267.

We also encourage you to voice your experience with your scheme on our Forums, including their response as well as the response from Council, if any. Please read our forum guidelines first, to ensure we maintain a useful, fair and dignified presence.

The post How do I complain about a medical aid issue? appeared first on Medical Aid Bible.

Determining when you can change your medical plan depends on whether you want to stay with the same scheme or not.

Staying with the same scheme

If you want to change plans, but not schemes, you can always do that at the end of the year, to start from January of the following year. Confirm deadlines with your scheme, or subscribe to our newsletter (below) and we will remind you of any deadlines when the time comes.

Most schemes will allow you to downgrade your plan at any time.

Some schemes might allow you to upgrade your plan at any time. Speak to them directly.

Some schemes will allow you to upgrade your plan to a higher plan in the middle of the year if you have been diagnosed with a condition that requires better coverage (for example, Bestmed will allow you to upgrade your plan if you have been diagnosed with cancer, and your current plan only allows treatment in State hospitals). Some schemes will place a time limit on this upgrade (for example, you need to change plans within 30 days of a new diagnosis).

Changing schemes

If you want to change schemes, you can do so at any time.

You cannot be a member of two medical schemes, so you need to time your change carefully: you need to resign from one scheme the day you become a member of the new scheme.

Note your schemes notice period. Most schemes have a 30 day notice period, but Fedhealth, for example, has a three month notice requirement.

What else should I know?

If your current plan has a savings fund, and you change plans in the middle of the year, your scheme will calculate how much savings you were entitled to on a pro-rata basis. If you have used less than this, they will refund you. If you have used more, you will need to pay it back.

If you change plans in the middle of the year to one that has limits on benefits, know that those limits will be worked out on a pro rata basis for the year. For example, if you join mid-year, and a benefit usually has a annual limit of R5,000, only half of that will be available to you for the remainder of the year.

When changing plans, be aware of waiting periods.

Also read How do I change my plan?

The post When can I change my medical aid plan? appeared first on Medical Aid Bible.

The Medical Act allows waiting periods to be imposed so as to prevent potential members from joining a scheme as they become ill. The idea is that members should join a scheme while they are generally healthy. It is, however, freely admitted by the department of Health and the Council of Medical Schemes that the legislation governing waiting periods was poorly drafted, and can result in medical schemes exploiting members who are “not necessarily engaging in opportunistic behaviour“.

There are two types of waiting periods: 3 month general waiting period and 12-month conditional waiting period.

3 month general waiting period

This is a waiting period that can be applied to all health services for the first 3 months of membership, including in some cases PMBs ie life-threatening conditions. For example, if you are involved in a car accident during this waiting period, it is very possible that you will not receive any coverage from your scheme for any claims.

12 month specific condition exclusion

According to the Act, schemes can restrict treatment for certain conditions for which “medical advice, diagnosis, care or treatment was recommended or received within the 12-month period ending on the date on which an application was made“. Even if some schemes ask for a medical history that extends beyond the past 12 months, they are not allowed to impose restrictions based on any medical history older than 12 months.

Which of the two exclusion, if any, can apply to you depends on your specific circumstance.

1.
You want to change plans within the same scheme.
Exclusions: None can be applied, although any current exclusions will continue.

or
2.
You have not been a member of a scheme for more than 90 days
Exclusions: Both the 3 month general exclusion (including PMBs) and the 12 month condition-specific exclusion (including PMBs) can be applied.

or
3.
You are changing schemes voluntarily, and have been a member of a scheme(s) for less than 24 continuous months.
Exclusions: The 12 month condition-specific exclusion (excluding PMBs) can be applied. No general 3 month exclusion can be applied.

4.
You are changing schemes voluntarily, and have been a member of a scheme for the past 24 continuous months or longer
Exclusion: Only the 3 month general waiting period (excluding PMBs) can be applied.

1. You are changing schemes involuntarily due to change in employment
   Exclusions: Generally, no exclusions can be applied.

Waiting periods and PMBs

Waiting periods that exclude PMBs mean that you must be treated for all PMBs during the waiting period (for example: injuries due to car accident).

Waiting periods that include PMBs mean that you will not receive treatment for PMBs, even life threatening ones (car accident). Some schemes might cover you for some PMBs, at their discretion.

Note that during the waiting period, the schemes are obliged to only offer coverage for PMBs according to the PMB level of care ie. through designated providers, including state hospitals only.

You can find out more about PMBs here.

It’s all at the discretion of the scheme

Schemes cannot impose more exclusions than allowed by law, but they can impose less. Speak to your potential new scheme to get clarification regarding waiting periods in your specific case.

You might also be interested in Late Joiner Penalties or “Waiting periods and pregnancy“.

The part of the ACT that deals with waiting periods:

The post What are “Waiting periods”? appeared first on Medical Aid Bible.

A medical scheme is generally not allowed to refuse you membership, including on the grounds of past-ill health, or you being a high risk.

A scheme, can, however impose waiting periods.

A scheme is also not allowed to charge you a different (higher) premium because of your past medical history. It can, however, impose a “late joiner penalty”, which can range from an extra 5% to extra 75% of the premium, depending on your age and how long you have not had medical aid coverage.

The post Can I be refused membership of a Medical Aid Scheme? appeared first on Medical Aid Bible.

Changing a plan within the same Scheme

You can do this towards the end of the calendar year, for the following year. Subscribe to our newsletter (below) and we will inform you of all deadline closer to the time.

Most often, you will be requested to fill out a “Change of plan” form, which you simply need to submit by the deadline. Of course, if you have a broker, you can just use their services for this.

Changing to a different scheme

You can do this at any time. Read our article on Waiting Periods that apply when you change schemes.

1.
Find the best plan for you, and ask the scheme to contact you using our “sign up for this plan” links.

2.
The scheme will send you an application form. Fill this in, making sure you disclose all relevant information. (Not doing so can result in cancellation of your membership at a time you need it most).

3.
The scheme should then send you a quote, and detailed explanation of any waiting periods and late joiner penalties that will apply to your new membership.

4.
Accept the quote, and confirm with your old scheme when your membership can be cancelled. Most schemes require one calendar month notice. Fedhealth requires 3 months notice. Ensure your new membership activates the day after your old one ends. You cannot be a member of two schemes at the same time.

5.
If you had a savings account or other similar benefit with your old scheme, it is possible that you will owe them money for benefits used up over and above the pro-rata allocation of the funds to the date of your resignation. You will need to pay this difference in cash to the Scheme. (Example: if you used your entire savings account for the year, but only paid six months of premiums at your resignation date, you will be liable for six months of the savings portion of your premium.)

Also read When can I change my plan?

The post How do I change my medical aid plan? appeared first on Medical Aid Bible.

A Designated Service Provider (DSP) is a healthcare provider (doctor, pharmacist, hospital, etc) that is a medical scheme’s first choice when its members need diagnosis, treatment or care for a PMB condition (see below for definition of PMBs). (source: Council for Medical Schemes)

Extended Benefit

This is “extra” coverage, usually for an out-of-hospital benefit, that is paid for by the scheme and not out of your medical savings. The Medical Aid Bible includes it with all the “day-to-day” benefits for each plan.

Formulary

This is a list of approved medicines for each condition. Each scheme has its own list/formulary which determines how it pays for medication. Some schemes have different lists (formularies) for diffrent plans.
If the medication you need is not on the formulary, the scheme might not pay for it, or might ask you for a co-payment.

MMAP

MMAP (Maximum Medical Aid Price) serves as a guide to determine the maximum price that medical schemes will reimburse for generic medication. You can download the price list here.

Network Provider

A healthcare service provider (doctor, pharmacy, hospital, optometrist etc) with whom the scheme has a payment or service arrangement.
Your plan might limit you to only providers in the network, or might require you to make a co-payment if your provider is not part of the network.
Often, if you use network providers, the scheme will cover the cost in full, but check your plan for details.

OAL: Overall Annual Limit

This is the maximum amount that the plan will pay to cover claims (in and out of hospital) for you or your family, per year.
Most plans have an unlimited OAL, but have sub-limits that apply.
OALs do not apply if you need to be treated for a PMB (see below) and have reached your OAL limit.
In other words, even if you have reached your limit, you cannot be denied treatment for a PMB.

PMBs

A PMB, or a Prescribed Minimum Benefit, is a set of conditions and their treatments that every plan must cover, regardless of what plan you are on, how much money (if any) is in your medical savings account, how much money you have already claimed etc.
There are 270 recognised PMBs, including all emergency (life threatening) conditions and 27 chronic conditions.
We have a more detailed explanation on PMBs here.

PPN

This is a specific network for optical benefits. Some schemes require that you use this network for all your optometry needs. You can read more on the PPN website.

Risk

Most in-hospital claims and some out-of-hospitals plans are paid “from Risk”. That means that the scheme pays for them out of its funds, not out of your funds (such as your savings fund). Essentially, “from risk” means “paid by scheme”.

Scheme Tariff

Plans cover your claims according to 100% or 150% or 200% or 300% Scheme Tariff. The Scheme Tariff is a pre-set amount that the Scheme will pay for a service.

For example: If a Scheme’s 100% tariff for a GP consult is R250: