Terms to understand when talking about medical aid

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Terms to understand when talking about medical aid

The time has come to step up as an adult and become the principal member of your own medical aid. You may be looking around at different medical aid schemes and comparing prices, benefits and cover rates already. But, if you're being honest, do you even know what you’re looking at and trying to compare?

Medical aid terminology can be confusing and with the ever-pressing need for medical aid constantly proving evident in your life, you may be led to just take the first one you see that you can sort of afford. That’s not the right way to go about choosing medical aid. So, to help you out a little bit, we’ll be going through some of the various terms (in alphabetical order) that you’ll undoubtedly come across when reading through medical aid brochures.  



When you see the term “copayment” followed by an amount of money, that is what you can expect to pay for a specific medical-based service. How it works is that your medical scheme will cover you for a certain percentage of what the medical practitioner charges for their service and the remainder of what’s not covered will have to be paid out of your own pocket.

Having to pay copayments for appointments and procedures will still be significantly less than if you were to pay for the procedure in full without the support of medical aid. So, while it may be “inconvenient”, you’re still saving money in the long run.

And if you’d prefer not to pay large copayments or any at all, you can stick to the Designated Service Provider (DSP) list supplied by your medical aid. This will be a comprehensive list of medical specialists and professionals who are in agreement with the chosen medical scheme in South Africa and set their rates accordingly.


Coverage and cover rates

Before we go any further, we need to clarify what is meant by coverage and what cover rates are as we’ve already mentioned them and will be mentioning them a few more times. “Coverage” in terms of medical aid is what the medical aid company is willing to pay for you, in the event you need any sort of medical assistance.

For example, if you need to go to the doctor and buy prescribed medication, you can submit the bill to your medical aid and they cover the costs for you completely (should it be a part of your medical plan).

Now, cover rates are the rates at which medical practitioners set their fees. Most medical aid schemes cover clients between 100% and 200% of the practitioner’s fee. Obviously, the higher your cover rate, the less you’ll have to pay should there be a copayment involved.


Hospital plan

A hospital plan is a type of medical aid plan that only covers you for in-hospital costs. In-hospital refers to everything involved, you guessed it, in the hospital. Hospital stays, scans, surgeries and treatments are usually covered in this plan. However, any out of hospital costs, such as doctors visits, dental visits, physiotherapy, etc. aren’t covered by a hospital plan. Well, not by all hospital plans anyway.

There are some hospital plans that come with extra benefits and coverage options which make them the ideal option for many people. They’re also, generally, more affordable than full-on medical aid plans because of their limited coverage.


Medical aid

Medical aid, on the other hand, consists of more comprehensive medical plans that cover both in and out of hospital procedures. There are different coverage options for medical aid that allow it to be more affordable for some by excluding certain medical services, and offer different cover rates with the different medical aid plans for affordability purposes as well.


Medical scheme

And a medical scheme is the company with which you have a medical aid plan. You pay them a monthly installment that allows them to cover your healthcare needs at more affordable rates. And the importance of these companies is that they can cover the bulk of a cost in the case of a medical emergency where you wouldn’t otherwise have the money to pay for it.


Prescribed Minimum Benefits (PMBs)

PMBs are exactly what you may immediately understand them to be. According to the Medical Schemes Act, there are certain medical instances (benefits) where the medical scheme is required to pay for the diagnosis, treatment and care of these listed medical cases. And these instances include any emergency medical conditions, as well as any medical condition that forms part of the 270 conditions listed by the Act. 27 of which are common chronic conditions.

With PMBs in place, you can be reassured by your medical scheme that you’ll be covered in the event of these medical conditions occurring, regardless of the plan you’re on. You may, however, be required to use a DSP and you’ll need to alert your medical aid of your condition in order for them to cover the claims.

Make sure you understand all there is to know about medical aid before you buy. It’s definitely something you want to do right.

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