Medical Schemes

How do I choose a medical scheme?
Choosing the right medical scheme is very important espcially when there are so many medical aid companies out there.

Can anyone become a member of a medical scheme?
Medical schemes used to have the right to reject applications from old or sick applicants, but they may no longer do so legally.

What are day-to-day limits?
Knowing the limits of you medical schemes and hospital plans are very important. Here's what you need to know.

Can one person belong to more than one medical scheme?
No person may belong to more than one medical scheme or hospital plan.

What is a self-payment gap?
Up to a pre-determined limit (which is different for every medical scheme) you will be liable for the payments until you reach what is called a threshold.

Who qualifies as a dependant on a medical scheme?
In terms of the Medical Schemes Act, no medical scheme may refuse to admit persons who are dependent on the member.

Does my employer have to subsidise my contributions to the medical scheme?
No, employers do not have to subsidise contributions of their employees to medical schemes or hospital plans.

Can a medical scheme terminate my membership?
Yes, if you belong to a closed medical scheme and you are retrenched or made redundant. An open medical aid can only terminate someone's membership if they do not pay.

What does it mean if a doctor is contracted in?
It means that that particular doctor will charge BHF rates to members of that particular medical scheme and you will not be left with large co-payments.

What are prescribed minimum benefits (PMBs)?
These are benefits in respect of relevant health services prescribed by the regulations under the Act.

If a member dies, will his registered dependants still be covered?
Yes, without any break in membership and provided contributions are paid. It is important to inform the medical scheme if one chooses not to continue.

What are day-to-day services?
Day-to-day services are all medical services where the member is not hospitalised. This will include your spectacles, medication, doctors' visits, specialist visits and so forth.

How do I select the option that's best for me?
Before choosing a medical scheme, you should take a careful look at your personal medical needs.

What is a co-payment?
Medical schemes seldom cover 100% of any medical bills. A co-payment is the portion of the bill for which you are responsible.

What is a medical savings account?
This is a fixed amount of money that a medical scheme member can choose to put in a savings account on a monthly basis.

What is an MSA?
Many medical schemes have what is called a medical savings account or MSA. It's usually a percentage of your monthly contribution, which is used to pay day-to-day medical expenses.

Who is SAMA?
SAMA stands for the South African Medical Association, which is an association for doctors in private practice.

Can I put my ex-spouse on my medical scheme?
If a court awards medical benefits to your spouse in a divorce case, you can keep your ex-spouse on your medical scheme.

If I resign from the scheme, until when can I claim?
You can submit claims for medical treatment up until the day your medical scheme membership or hospital plan expires.

How are medical scheme contributions determined?
There are three different things which determine medical scheme and hospital plan contributions.

What is a DSP (designated service provider)?
A healthcare provider or group of providers selected by the medical scheme as the preferred provider or providers.

May a medical scheme refuse to admit my dependant?
No, in terms of the Medical Schemes Act, no medical scheme or hospital plan may refuse to admit persons who are dependent on the member.

Can you still claim if you have given notice to leave the scheme?
You are still covered for medical treatment from you medical aid until the last day of your notice period.