Cheap Medical Aid Terminology Explained
When browsing for cheap medical aid options you will come across some terminology that may make it difficult to decide because you don’t understand the meaning of the words. We have provided more information on such terms as an understanding of the wording is essential for informed decision making regarding cheap medical aid and hospital plans in South Africa.
Chronic Disease List (CDL)
It is a list of chronic diseases forming part of the Prescribed Minimum Benefits (PMB) which any medical aid in South Africa should cover in state hospitals. The list is viewable at the Council for Medical Schemes and includes about 25 chronic diseases as well as over 270 emergency conditions. The Medical Schemes Act No. 31 of 1998 stipulates such conditions.
Day to Day Benefit
It is the combined out of hospital benefits covered by the medical aid scheme. Such includes radiology done for investigative purposes, optical services, GP, specialists, pathologist services and medical services rendered outside a hospital. This also includes prescribed medicine and related services such as specified self-medication.
Designated Service Provided (DSP)
A DSP is an appointed and approved service provider that renders healthcare to the medical scheme’s members according to the tariff structure agreed upon. The DSP is also the only service provider covered by the medical aid. Even if the service provider offers a cheap medical hospitalisation service, and is not one of the appointed ones, the service will not be covered as part of the member benefits.
Medical Scheme Tariff (MST)
It is a tariff that the designated medical aid scheme is willing to pay for specific treatments out of and in hospital for services rendered by the DSP.
Emergency
It is important to understand the Medical Schemes Act No. 31 of 1998 stipulates that medical aids must cover specific minimum conditions and treatments including emergency care. An emergency is a condition for which immediate care, surgery or hospitalisation is needed and without which the member will die, suffer long term serious health conditions, loss of functionality or lasting damage to organs or limbs. Such a condition is sudden and unexpected.
Elective Surgery
Most of the cheaper medical aid options do not include any form of elective surgery. There may be instances when such can be motivated and for which there will be cover, but it must be discussed with the specific Scheme and will be subject to pre-authorisation and specific limits. In essence, it is surgery to correct a non-life threatening condition including cosmetic operations. Emergency surgery is the opposite and is when the operation must be done to save the member’s life or prevent permanent or long term damage to the health of the patient.
Dental Information Systems (DENIS)
The DENIS is a service provider that the medical scheme contracts for management of dental benefits on behalf of the Scheme.
Limits
The limits are the maximum benefits payable for a member and dependants in one year for out of hospital costs. The financial year for a scheme normally starts on the first day of January and ends on the 31st of December. There are limits for each category such as medication, optical care, physiotherapy, and GP visits.
With most of the cheaper scheme options the limits for out of hospital care are often low, but for in hospital care more often than not 100% cover is provided to relatively high limits. If the medical scheme covers 70% of a GP visit then the member is responsible for 30% of the payment to make up 100% of the requested tariff. As such, it is important to review the day to day limits for schemes should you wish to gain higher out of hospital limits. The co-payment is the portion of the costs payable by the member.
Note that you may not belong to more than one medical scheme at a time. Minors can become members, but you may not register members as dependants if they are over 21 and no longer living with you. Contributions can be made to the scheme on behalf of a minor. An open medical aid is one that is open to anyone and not restricted to specific groups. View our range of benefits and payment structures to select a cheap, but comprehensive option that will meet your cover requirements.
