Depending on the type of plan you signed up for, there are three sets of medical aid benefits available for the year. It is important for members to understand what these benefits mean and how it impacts on their healthcare needs. These days medical aids are becoming much more restrictive with managed healthcare to control spending. It therefore requires careful planning and participation by the member to ensure that the benefits last the entire year or at least most of the year. Realistically the medical aid benefits on most plans can fund the average person’s healthcare for most of the year but given the overuse of medical aid, fraudulent claims, unhealthy lifestyle and diseases like HIV which makes a person ill more frequently, the limits for these benefits are often not enough.
Types of Medical Aid Benefits
There are three types of medical aid benefits.
- Day to day cover (out-of-hospital)
- Chronic cover
- Hospital cover (in-hospital)
Most medical aids these days have a savings account either as the entire out-of-hospital cover or to cover part of it. The funds in the medical savings account is carried over to the next year if it is not exhausted. Otherwise each benefit limit is only valid for 12 months and is refreshed at the start of each year.
Out of Hospital Benefit
This cover pays for all your daily medical expenses on an out of hospital basis. This includes consultations and medicines when you visit your doctor or other healthcare provider. It also pays for medicines acquired at a pharmacy and different medical tests and scans.
The annual limit is dependent on the plan you opt for. There are usually set limits for different healthcare services or one single limit for the year to cover all treatment for all members of the medical aid. If exhausted then the scheme will utilize the medical savings account. Some medical aids only have the funds available in a savings account as the entire day-to-day limit for the year. Some medical aid plans may not have a monetary allowance but rather allow members only a certain number of visits for the year. Once this limit is exhausted you will have to start paying cash for your out of hospital healthcare needs.
This benefit covers you for medicines for your chronic condition for the year. Additional extras that are not medicines may also be included in this benefit at times provides that it is related to the treatment and management of your chronic disease.
There is an overall limit for chronic care for the year which is shared by the entire family. Once it is exhausted then members have to pay cash for their chronic medicines. However, the scheme will provide an unlimited benefit for the treatment of 25 chronic conditions as outlined under the prescribed minimum benefit clause provided that the patient uses the cheaper generic medicine in most cases.
The hospital cover pays for the medical costs when a person is in hospital. This includes the hospital stay, drugs utilized, doctor’s fees, tests and scans and surgical procedures provided that these are for essential medical needs. Cosmetic surgery, elective procedures and fertility treatment are not covered. Most medical aids will also pay for outpatient chemotherapy and radiotherapy from the hospital benefit.
Many medical aid plans these years have an unlimited hospital benefit. Other plans have may an annual limit starting from around R1 million. It depends on each medical aid and the individual plan. Outpatient chemotherapy and radiotherapy for cancer is subject to certain limits for the year even if the hospital benefit is unlimited. Medical aid members need to understand that this hospital limit does not entitle them to stay in hospital for as long as they wish. With managed healthcare, medical aids determine how long a person needs to recover in hospital irrespective of whether there are still sufficient funds in the hospital benefit.