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Medical Schemes | Medical Scheme Rate | KeyHealth Medical Scheme


Conduct Some Research before Selecting Medical Schemes

Some confusion exists about the difference between medical schemes and medical insurance. The former isgoverned by the Council for Medical Schemes and the latter falls under the Long, or Short Term Insurance Act, two distinctly different bodies.

Unlike medical schemes, insurance plans pay a set amount for every day spent in hospital, normally commencing after two or three days’ hospitalisation. The policy holder can use the money towards hospital expenses, to supplement a salary or for anything they choose, even if unrelated to their situation. This type of cover, also known as a Hospital Plan, is unlikely to include Prescribed Minimum Benefits.

Medical aids apply the Medical Scheme Rate, according to which they pay out for claims, which include claims for Prescribed Minimum Benefits, (PMB’s), which is a list of predetermined conditions that all medical aids have to cover, by law. Payments usually vary between different companies, as do monthly contributions.

25 or 26 chronic conditions are also specified as qualifying for Prescribed Minimum Benefits, but application to join a separate chronic care plan must be made. All funds have to cover minimum hospital based benefits for designated conditions.

Most will pay for generic drug substitutes in full, where they exist in place of the original drug, but charge a co-payment if the patient selects to use the original – it really all depends on the patient’s selected plan.

Many funds have a list of preferred service suppliers, also known as designated service providers, such as pharmacies, doctors and specialists. Should the patient choose someone not listed, cover may not be as comprehensive.

Once approved by the fund, medication for these conditions is not deducted from the patient’s day to day, medical savings account, but paid via the chronic plan. Without adopting this option, available funds will become depleted earlier than usual.

Medical aids are classified as being open or closed; this latter description means that membership is only for company employees, whose monthly contributions may be subsidised by the employer, or members of a union or particular profession.

Anyone at all can join an open scheme, as long as they pay their contributions regularly and on time, failing which their cover could be discontinued.

There are many things to consider and assess before you decide which fund you’ll join – it’s not only about cost, although your monthly contribution may well be near the top of the list of regular expenses, preceded by your bond and car repayment and perhaps school fees.

Assessment Checklist

  • What can you afford? Everyone wants the best and the top product, but can you afford it?
  • Your age and general state of health. A youngster is less likely to visit the doctor often than an older person, who may have an existing medical condition or require chronic treatment and medication.
  • Marriage status and dependants. Your cover should cater adequately for a family, if you have one. However, don’t forget to reassess your plan if your circumstances should change.
  • Remember, you need to have cover for unforeseen eventualities, such as a vehicle or sporting accident or any other medical emergency situation which may require hospitalisation and surgery.
  • Speak to friends and family and find out to which medical aid they belong and how they find their service, pros and cons.
  • When looking at who offers what, keep in mind that most of your contribution funds hospital expenses, while a smaller portion make provision for your day-to-day expenses.
  • Non medical scheme patients have to part with huge sums of money even before being admitted to a private hospital, so you must have membership if private healthcare is your choice.
  • Today, many funds have a network of preferred suppliers, in respect of hospitals, GP’s, specialists and pharmacies. Should you choose to go your own route, expect to have co-payments or pay penalties.
  • Get information on schemes’ cash reserves and establish whether they are financially stable.
  • How frequently are claims paid?
  • Is the claims procedure simple and easy or cumbersome and complex?
  • How efficient is administration and support services?

The answers to these questions should give you a reasonable idea of which fund would best suit you.

Our medical scheme is dedicated to caring for our members and their health with affordable options. We constantly strive be innovative in creating new methods and products for members’ benefit. We offer five different plans, so that prospective members have choices about the cover they need and its affordability.