Things You Should Know About Your Monthly Medical Aid Plan
Given that state-funded healthcare services are no longer able to meet the needs of a growing population in the face of rising costs and diminishing funds, the role of private hospitals and clinics in South Africa has never been more crucial. That being said, the expense of operating such facilities with their large staff and advanced facilities is correspondingly higher. As a result, without the benefit of a monthly medical aid plan, few of the nation’s citizens could possibly hope to meet the full cost of major surgery or a course of radiotherapy.
Today, close to 9 million South Africans are in receipt of financial support with their private healthcare costs. This support is provided by the approximately 90 such schemes that are currently operating locally and is made possible as the result of a total sum of almost R130 billion in premium contributions received annually from their members. In practice, it is estimated that as many as 95% of those who receive such treatment today would have been unable to do so without the help that they receive from their monthly medical aid plan.
Despite the vast number of people who now depend upon these schemes, there remain a surprising number of misconceptions about how they work and the rights of members. Firstly, although they operate on the same basis of shared risk as a traditional insurance company, these specialised organisations, are required to trade as section 21 (not for profit) companies. That means that they have no shareholders to whom annual dividends must be paid and, instead, any excess income that they may accrue must be retained for the exclusive purpose of financing the scheme’s ongoing operational needs.
In 1998, the provisions of the Medical Schemes Act meant that all monthly medical aid plans were now obliged to provide the additional cover described as Prescribed Minimum Benefits (PMB). This too is an area in which many members may need further clarification. There is a misguided belief that expenses arising from PMBs are only covered for hospital-based services. In practice, whether threated by a hospital consultant or a GP, schemes are under the same obligation to cover the consulting fee and the cost of any prescribed medication.
It is also worth knowing that this obligation on a scheme also applies to those members who may only have hospital plans, as well as to members who have exhausted their medical savings account or have reached the limit for certain benefits. While your monthly medical aid plan must also provide cover for diagnostic tests relevant to PMBs, this is only mandatory when employing the same tests employed within the state healthcare service and if it is used to confirm the diagnosis of a condition listed among the PMBs. In the case of such tests that yield a negative result, there is actually no obligation to cover the cost, although some schemes will.
Although a scheme may appoint designated service providers and may make claims conditional upon their use, some will make exceptions where a DSP (designated service provider) is not easily accessible to the member.
The terms and conditions governing a monthly medical aid plan can be confusing and that’s why KeyHealth has taken care to provide straightforward products that combine affordability with comprehensive benefits.