18 November 2009

Medical schemes - the basics

A medical scheme helps you to pay for your healthcare needs, such as nursing, surgery, dental work, medicine and hospital accommodation.


A medical scheme helps you to pay for your healthcare needs, such as nursing, surgery, dental work, medicine and hospital accommodation. It can be described as “insurance” you are taking out to cover your health costs. You (and in certain cases your employer) pay regular contributions to the scheme.

Why should I have a medical scheme?
There are many advantages to belonging to a medical scheme.

  • It financially protects you if you suddenly have to pay large, unexpected medical costs.
  • If you have a medical scheme, you can usually rest assured that there will be no delay in your medical treatment because you don’t have funds to pay for it.
  • Being a member of a scheme also means you get better medical care because you are treated by private doctors, specialists and hospitals, instead of overcrowded public health services.

What are the disadvantages of a medical scheme?

  • It is expensive and fees are always increasing.
  • If you live in a rural area, it often does not make sense to have a medical scheme, because of a lack in private health care facilities.
  • There are often many hidden costs involved with schemes. Your scheme might only pay a small amount of your healthcare costs, while you have to pay the rest out of your own pocket.

How many medical schemes can I choose from?
South Africa has about 119 medical schemes totalling around 7 million beneficiaries. (Our country has a population of more than 47 million people, so less than 15% of South African citizens belong to a medical scheme.)

Not all medical schemes are open to the public. Of the 119 medical schemes, only about 37 (end of 2008) are open to the public. This number might decrease over the years as the larger schemes take over the smaller ones.

Who are the largest medical schemes in South Africa?
Of the approximately 37 (end of 2008) open medical schemes in South Africa, these ones are some of the largest: (in no particular order)

  • Discovery Health Medical Scheme
  • Fedhealth Medical Scheme
  • Resolution Health Medical Scheme
  • Momentum Health Medical Scheme
  • Genesis Medical Scheme
  • Medihelp Medical Scheme
  • Oxygen Medical Scheme
  • Profmed Medical Scheme
  • Bonitas Medical Scheme

How does a medical scheme work?
A medical scheme is a non-profit organisation and should be registered at the Registrar of Medical Schemes. Members belonging to a scheme make contributions and in return receive medical cover according to the rules of the scheme. Each medical scheme must provide a minimum set of benefits to its members.

There are two kinds of schemes – open and closed schemes. Any person can join an open scheme, but closed schemes are for specific employer groups.

A medical scheme is managed by a board of trustees who are elected by the schemes’ members. They are responsible to manage the scheme to the benefit of its members.

How do I choose a medical scheme?
It all depends on your specific healthcare needs and which company can offer you the best option to suit these needs. The medical scheme industry is ever changing and that’s why it’s important to get help in choosing the right scheme. To help you make the right decision, it is often best to use the service of an independent intermediary or healthcare consultant.

All about Optivest

How to choose a medical scheme?

Do I have options?
Yes, you have a wide range of options. Every medical scheme offers different sets of benefits (options) you can choose from, depending on your healthcare needs and budget. To help you choose between medical schemes and hospital plans, specific options the schemes offer and which benefits to include or exclude, it is best to use the services of an independent intermediary or healthcare consultant.

What other alternatives are there to medical schemes?
You can take out a hospital plan insurance policy from an insurance company that provided a fixed amount of cover for certain listed procedures. Then, some unions run medical benefit schemes for their members. Medical benefit schemes can be much cheaper than medical aid schemes, but offer limited cover.

What should a medical scheme pay for?
The Medical Schemes Act of 1998 says that medical schemes must, according to law, at least pay for the treatment of a certain list of conditions as well as a list of procedures. These conditions and procedures are called PMBs (prescribed minimum benefits). To find out which conditions and procedures must be covered by your scheme, click here.

What are my rights according to the law?
The Medical Schemes Act (No 131 of 1998) came into effect on 1 January 2001. According to this act:

  • There are standard-rate fees for people to join medical aid schemes regardless of their health or age
  • There can be no discrimination on grounds of peoples' health. For example, a medical scheme cannot refuse to allow someone to join because he/she is HIV-positive, or because they have asthma or diabetes.
  • The definition of dependants includes spouses, life partners and natural and adopted children.
  • The new Act also sets out a complaints procedure for people who have a complaint against a medical scheme.

Medical schemes- a history
You and the medical schemes act
Where to complain

Keeping your medical costs down
There is a lot that you and other consumers can do to keep healthcare costs in check. Here follow a few tips:

  • Use generic medications where you can, but make sure that you read the inserts carefully. Dosages may differ from the original tablets you were taking.
  • Early detection of many conditions will, in most cases, reduce the treatment costs.
  • Check your hospital bill carefully. There is an increasing tendency to charge for items that were not given to the patient. If you have paid for a packet of 60 tablets and you use only 30, the balance should be given to you.
  • Use your pharmacist for advice on day-to-day illnesses and treatment.
  • Shop around. Get onto the phone and compare tariffs and prices charged by different doctors or pharmacies. They could differ vastly.
  • Use the internet to get medical information on your condition and how to stay healthy. A reputable site will help you make informed decisions about your health and the treatment choices you have.
  • Negotiate, negotiate, negotiate. Don't be shy to ask healthcare providers if they are prepared to charge medical scheme rates. Negotiate with his or her receptionist or bookkeeper if you are too shy to speak to the doctor. You have nothing to lose. On the other hand, the doctors do. If all their clients went elsewhere, where rates were cheaper, they'd be out of business very swiftly.
  • Do check your monthly statements. Every now and then it could happen that a rogue healthcare provider will bill your medical aid, even if you haven't seen them for months. Keep your eyes open.
  • Make sure that you understand the benefits from your medical fund and use them judiciously.

(Susan Erasmus, Health24, updated November 2009)


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