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Medical Aid: Help with Terminology

We understand that when you look for the right medical aid, help with terminology can come in handy. It’s simply easier to make an informed decision regarding the right medical aid and benefit plan for you, if you at least understand the terms used.

We thus provide essential help to understand terminology. You can call our service centre and have a consultant explain all the terminology and benefits packages or you can make use of the online chat facility for such. In addition, help is given below for immediate understanding of wording used in medical aid covers.

Reference Pricing

The reference price refers to the maximum price a medical aid is willing to pay for drugs that is listed on the Condition Medicine List for the specific condition. One should note that a reference price is applied for a specific benefit option. The price stipulated at, for example the Silver Plan, may be less than the upper limit stipulated at the Gold or Platinum benefit plans.

Reviewing of Reference Prices

The medical aid scheme reviews the reference prices once a year. Considerations for the upper limit include whether the drug is to be discontinued, availability of alternatives, licensed indications, and patent expiry or price changes.

How Reference Pricing Works

With the reference prices, we give patients control over their spending. If the medication prescribed is above the price we’re willing to pay, the patient can substitute the medicine with a generic and therefore clinically approved alternative. In most instances the generic alternative will be cheaper, allowing the patient to save on out-of-pocket costs. The patient also has the choice of keeping with the more expensive medicine even though alternatives are available and then pay the difference between the reference price and the price it is offered at.

Prescribed Minimum Benefits

The Medical Schemes Act No. 131 of 1998 governs medical schemes in South Africa. According to the terms in the Act, specific conditions must be covered by medical aid benefit plans. The PMBs cover such treatments available in public hospitals. These benefits are available irrespective of the benefit plan or medical aid selected and should be available to the members regardless of their state of health or age.

Medical aids must cover costs regarding medical emergency conditions and conditions forming part of the prescribed conditions in Diagnosis Treatment Pairs. The medical professional treating the patient makes the decision whether the condition falls within the PMB category.

Pre-Authorisation for Hospitalisation

Pre-authorisation is required before the patient is admitted to hospital. We provide a telephone number for such. To ensure that authorisation can be given we require the membership number and details of the patient to be admitted to hospital. Information such as the reason for hospitalisation or for a specific treatment, date of admission and planned date for any scheduled procedures, as well as the name and practice number of the medical facility must be provided. We also require the particulars of the service provider such as initials and surname, contact, and practice numbers.

When a doctor thus recommends hospitalisation, it’s imperative to ask for the reason, information about the diagnosis and prospective procedures to be carried out. Once the authorisation is given the member is issued with a relevant authorisation number.

In the instance where the patient must be admitted to hospital for an emergency and as a result doesn’t have the time to request authorisation, it’s important to obtain such information within 24 hours of admission. Where the patient cannot do so because of their health state, the hospital or a family member can contact the Authorisation Centre with the required information within 48 hours.

Pre-authorisation helps the medical scheme to manage costs and to ensure that the patient receives relevant and needed treatment.

Claims

Claims refer to the request for payment for services and drugs supplied by the authorised service provider. In most instances, the service provider submits the claim on behalf of the medical aid member. In the instance where such is not the case, the member must submit the claim. It’s imperative to check claim statements monthly to determine whether the service provider has claimed and that the claim is for the correct treatment.

Call us for more information and medical aid help to ensure that you understand the terminology used in our benefit plans.

About Us

KeyHealth is an open medical scheme, offering a comprehensive healthcare product range that caters for the medical aid needs of both individuals and groups. The Scheme provides medical cover to more than 95 000 lives throughout South Africa.

KeyHealth is also one of the five medical schemes accredited to operate within the Local Government sector.