Whether a paid employee or a self-employed entrepreneur, the average South African will acknowledge the importance of medical aid, but what does it cover? To some extent, the answer will depend on how much one is willing to pay for the benefits provided, and these can differ widely between the available options.
However, the Medical Schemes Act 131 of 1998 led to the formation of the Council for Medical Schemes (CMS), a statutory body tasked with regulating and monitoring the industry’s activities. Under its mandate, all schemes were now legally bound to include cover for certain prescribed minimum benefits (PMBs) with every product, regardless of its price tag. Let’s examine these mandatory benefits in more detail.
Medical Aid and Prescribed Minimum Benefits
PMBs are intended to satisfy four goals:
- Firstly, the concept aims to ensure healthcare is always available to everyone who requires it, irrespective of age or general health.
- The legislation also ensures scheme members have access to continuous healthcare. Even if a member’s annual benefits limits have been reached, a scheme must still settle all claims related to prescribed minimum benefits.
- In addition, this provision ensures qualifying members’ treatment costs will always be met. Claims will be paid even if a state-funded facility provides the necessary services.
- The concept also holds a long-term benefit for medical aid schemes. Ensuring patients with PMB conditions receive ongoing quality care can help improve their general wellness, enabling them to avoid the more severe consequences that tend to give rise to much bigger claims.
General Benefits for Medical Aid Members
It is at this point that the premium price has an influence. When insuring the contents of your home, the monthly premiums will be based on the total value of the items to be covered. Not surprisingly, the nature and value of the benefits included in a medical scheme’s products will tend to have a similar influence.
The term “benefits” refers to a list of the services for which a given scheme undertakes to pay and any limits that might be applied to relevant claims by the member. The list will detail a range of healthcare services, and, like PMBs, assistance with hospitalisation costs is a feature of all products. Hospital plans are an affordable entry-level option whose benefits are limited mainly, but not entirely, to inpatient treatments but may include additional services such as optometry, conservative dentistry, preventative medicine and psychiatric counselling.
More comprehensive products still address the member’s inpatient needs but also cover a wide range of day-to-day and non-urgent contingencies. These could include specialised dentistry, maxillo-facial surgery, GP and specialist consultations and over-the-counter medications, and higher limits to claims in general.
Medical Aid Terms and Conditions
All schemes must provide detailed documentation explaining their terms and conditions to ensure members fully understand their benefits and are alerted to any limitations that might apply to their treatments or claims. These might include requirements, such as obtaining pre-authorisation for specified procedures and drawing attention to the mandatory waiting periods that apply to first-time members and those with a pre-existing illness.
Schemes that operate a network of designated service providers (DSPs), such as clinics, pharmacies and specialists, might also alert members to the possibility they could incur co-payments when seeking treatment from non-network sources.
Medical Aid with a Savings Account
A typical fully-comprehensive product usually includes an unlimited hospital plan and a list of predefined sums that will apply to claims for specified day-to-day medical expenses. However, members sometimes find those allocations are not all relevant to their needs. Some products allocate a portion of the premiums to a medical savings account, allowing members to utilise it to manage their out-of-hospital expenses more appropriately based on specific rather than generalised needs.
Six Reasons to Choose Medical Aid from KeyHealth
Of around 170 schemes launched in the ‘60s, few have survived. Those operating today are mostly relative newcomers or the product of mergers. KeyHealth is one of the survivors. Potential members can have confidence in us for the following reasons and more:
- Over 50 years of providing cover for South Africans
- A choice of six products to suit all needs and budgets
- Above average solvency ratio and AA- international credit rating
- An integrated care programme
- Our DSP network eliminates co-payments
- Three unique free core benefits for all members
But don’t take our word for it. Instead, click here to review our 2023 benefits in more detail.
