The medical aid industry is notorious for using potentially bewildering jargon and terms that not everyone is familiar with. This can make it tricky to untangle different medical aid plans and what they're really offering.
Here we provide simple definitions of common medical aid terms used in South Africa.
agreed tariff
A set rate negotiated between a medical aid scheme and service providers. The scheme usually pays this directly to GPs, specialists, pharmacies or hospitals.
associated network options
Medical aid options, or plans, for which a network of healthcare practitioners provides services at an agreed tariff.
algorithm
A defined, step-by-step process for treating or managing an illness or medical condition optimally.
alternate healthcare providers
Complementary healthcare professionals such as dieticians, hypnotherapists, acupuncturists and nutritionists.
benefits
Healthcare services, procedures and medicines covered by your monthly contribution. The benefits you'll receive depend on the type of medical aid plan, or option, you choose.
branded medication
Patent-protected medicines with registered trade names.
chronic condition
A long-lasting illness or disease that typically requires on-going treatment and care. Often a condition is called chronic if it lasts for more than three months.
chronic disease list (CDL)
A list of 27 chronic conditions that are automatically eligible for state sanctioned prescribed minimum benefits (PMBs) and are covered by all medical aid schemes in South Africa.
comprehensive cover
A medical aid option that offers both in-hospital and day-to-day benefits.
co-payment
A portion or percentage of healthcare costs not covered by a medical scheme and for which the member is personally liable.
day-to-day benefits
Cover provided by a scheme for day-to-day expenses such as GP and specialist consultations, prescribed medication and procedures, pathology and radiology conducted out of hospital.
designated service providers (DSPs)
A network of healthcare professionals with whom a medical aid scheme has pre-negotiated rates. Depending on the plans they've chosen, a medical aid scheme may require members to use only designated healthcare providers or to pay co-payments if they use other providers.
disease management programme
A dedicated and structured management programme run by scheme professionals and designed to help members living with chronic conditions.
exclusions
Medical procedures or conditions not covered by a particular medical aid scheme. Common examples of exclusions are cosmetic surgery and self-inflicted injuries.
generic medication
Non-branded medicine that has the same active ingredient and is similar in strength and performance to branded medication but that's available at a substantially lower cost.
generic reference pricing
The maximum amount a medical aid scheme will pay for a class of generic medicines.
hospital plan
A medical aid plan that covers only consultations and procedures that occur in hospital and the listed/chronic illnesses.
hospital plan with savings
A medical aid plan that covers consultations and procedures that occur in hospital, and that retains a percentage of a member's monthly contribution in a medical savings account, for use in paying for day-to-day expenses.
ICD-10 codes
A globally accepted disease classification and coding system that identifies diagnoses, symptoms and procedures. Medical aid schemes use the codes to determine what benefits a member is eligible for and how these benefits must be paid.
income-based plan
Low-cost medical aid for which contributions are based on the member's monthly income.
medical savings account
A savings account provided by a medical aid scheme and funded by a percentage of the member's contribution. The funds are used to pay for day-to-day medical expenses.
National Health Reference Price List (NHRPL)
A set of baseline tariffs designed by the Council of Medical Schemes (CMS). It serves as a rates guideline for healthcare practitioners and medical aid schemes.
network options
Also known as capitation plans, medical aid options that cover costs only for healthcare services provided by designated service providers (DSPs). Members who consult other healthcare providers are typically liable for co-payments.
prescribed minimum benefits (PMBs)
Minimum benefits that medical aid schemes are legally required to cover for a set of approximately 270 listed medical conditions, as outlined by the Medical Schemes Act.
Risk
This is usually amounts that schemes cover that are not related to the members: day to day benefits.
self payment gap
A gap in cover when funds in the member's savings account are depleted but the annual threshold has not been reached.
scheme rate
A defined rate at which a medical aid scheme pays service providers. If the charged tariff exceeds the scheme rate, co-payments apply.
sublimit
A defined limit that applies over and above the overall limit on a particular benefit.
threshold
Certain medical aid plans require members to pay for day-to-day expenses from a medical savings account, or their own pockets, up to a specified amount, known as a threshold. Once the limit has been reached, the medical scheme pays for any further claims, up to a prescribed amount.
If you're struggling to make sense of South African medical aid terms and options, contact us at IFC - we specialise in finding the best possible medical aid options based on your budget and healthcare needs.
