I’m young, fit and healthy; why should I need to pay premiums towards a medical aid scheme? Surely, that money could be better utilised?” These are two questions that go through an individual’s minds when considering medical aid cover. The reality is that we can’t predict the future and the question you should really be asking yourself is “can I afford NOT to have medical cover?” Think of it as a long-term contingency plan that is in place should an unforeseen event that affects your health occur.

Another reason people opt against medical aid cover is that it can be an arduous process; the complicated fine print; foreign terminology; codes and formularies are not coffee table reading. In this article, we’re going to breakdown medical aid schemes to give you a better understanding of this essential, potentially lifesaving product. Did you know that certain employers opt for a group medical aid scheme to cover employees’ health? This benefit should be stipulated in your employment contract.

What is a medical aid scheme?

Medical aid schemes are actually non-profit organisations. The money is pooled together by individuals who pay a monthly premium or contribution, and the money is accessible when he/she needs to pay different healthcare expenses.

What does my medical aid scheme cover?

The expenses that you can claim from your medical aid scheme depends on your specific plan; there are a variety of tiers that dictate the benefits of your cover. Medical aid schemes generally range from hospital plans to comprehensive plans. A list of all plans should be available on the medical aid scheme companies’ website.

All plans are regulated, governed by South Africa’s Medical Scheme Act so that you have access to healthcare when you need it most.

You may be able to get healthcare coverage through your employer

Employers can choose to have a group medical aid scheme which offers healthcare benefits to all their employees. However, the type of plan is decided by them, and the monthly premium will be deducted from your salary. Another question you may be asking yourself is “what if the premium is more than you would pay if I belonged to another medical aid as an individual, not an employee? Can my employer force you to belong to a specific medical scheme(s)?” Yes and no.

Yes. Companies in South Africa may enforce membership of a particular medical scheme(s) if it is provided for within the framework of conditions of service. This may be the case if you work for an employer who has a closed medical scheme.

No. You don’t have any obligation to belong to your company’s chosen medical scheme if it’s not provided for in your employment contract.

If you are employed on a cost to company (CTC) contract, which is typically the approach companies follow, you should be able to belong to any medical scheme of your choice.

As mentioned above, there are closed and open schemes.

Closed schemes: Restricted (also known as closed) medical schemes are overseen on behalf of companies for their staff members and their families. They can also be joined by people working in a particular industry.

Open schemes: In contrast, open schemes, are open to the public and anyone can join if they are over the age of 18, are not currently a member of another medical scheme and can pay the monthly contributions.

Deciphering terminology

There are specific terms that are commonplace to all medical aid schemes in South Africa. Here are explanations to a few of them.

Open enrolment

All medical aid schemes must accept all applicants and charge them the same monthly contribution (depending on their chosen plan), irrespective of his/her age and health status.

Regulatory reserve requirements

When a member joins a medical aid scheme, it should hold 25% of the yearly contribution in cash reserves from the first day that membership has been approved (even before the member has paid his/her first contribution).

Prescribed Minimum Benefits (PMBs)

All medical aid schemes need to offer a set of minimum healthcare conditions and procedures; these are known as Prescribed Minimum Benefits (PMBs). Schemes are able to use tools such as designated service providers, networks and formularies to manage expenses connected with PMBs.

Networks

Some plans, benefits and healthcare services require you to use the medical aid scheme’s network providers. If you choose not to use one of these providers, your expenses will not be covered, and you’ll be liable for the full amount.

Chronic Disease List (CDL)

The Chronic Disease List (CDL) is a list of conditions that the medical aid scheme covers according to their prescribed minimum benefits

What is gap cover?

Your medical aid scheme may not cover all of your medical expenses; it depends on your plan. In some instances, doctors and specialists charge rates that are above medical aid scheme rates, which results in a shortfall. Gap cover is a short-term insurance policy that works in conjunction with your medical aid and covers the shortfall (the amount which you would have to pay out of your pocket.)  

Conclusion

It may feel like a grudge purchase, but it’s vital that you become a member of a medical aid scheme.

• It protects you financially if you suddenly need to pay a high, unanticipated medical cost that you otherwise couldn’t afford to pay.
• If you belong to a medical aid scheme, you can typically have peace of mind that there will be no timeous delays in your medical treatment because you have the coverage.

Please speak to one of our consultants. He/she will provide you with more information about finding a medical aid scheme that suits your needs.