Healthcare is an extremely specialised industry. Hospital and healthcare costs are escalating rapidly and the options are daunting and often difficult to compare and evaluate. So, whether you have a company that requires a medical aid scheme for employees, or you are an individual who needs health cover we help you make sense of the options so that you can make an appropriate and cost effective choice.
What is chronic medicine?
This is medicine that you need to take on a daily basis over a long period of time. Not all medicine that is taken for a long period of time will be paid as chronic. Although a condition may be defined as chronic, we may not be able to cover it from the Chronic Illness Benefit. According to Legislation all medical aids need to cover you for the prescribed minimum benefit which equals to 27 chronic conditions. The Chronic Illness Benefit is a benefit that covers medicine for a specified list of chronic conditions according to your plan type For your medical aid to cover medication as chronic, it needs to get approved by the scheme according to the scheme rules. Complete a chronic medication application form and submit to medical aid for approval. Every medical aid has its own formulary of medications that will be covered on the chronic illness benefit. The medical aid will pay claims if they have approved your condition on the chronic illness benefit. They pay for diagnostic tests from the chronic illness benefit only if your claim for the investigation is dated up to one month before your application for cover. If they receive claims dated earlier, they will pay the claims from your day-today benefit.
What is claw back?
A member’s medical aid contribution consists of a Risk portion and a Medical Savings Account (MSA) portion. Although the MSA portion is paid on a monthly basis over a period of 12 months, the full 12-month portions are allocated to the available MSA Balance at the beginning of the benefit year. Should the member/beneficiary resign during the course of the year, the MSA allocation is pro-rated and offset against the medical expenses incurred as at the date of resignation. In the event of the medical expenses exceeding the pro-rated MSA allocation, the exceeded amount is debited against the member as a claw back.
What is generic vs. patented drugs?
Generic drugs are copies of brand-name drugs that have exactly the same dosage, intended use, effects, side effects, route of administration, risks, safety, and strength as the original drug. Generic drugs are only cheaper because the manufacturers have not had the expenses of developing and marketing a new drug.
What to do when you need to be admitted?
Before you go to hospital for any planned procedure, you must: See the doctor Check what rate your specialist charges you Compare this to the cover on your medical aid Check if you will have any shortfall or co-payment Authorise your hospital admission with medical aid Cover for all the costs while you are in hospital is not automatic.
When you know you are going to be admitted to hospital, you need to tell the medical aid beforehand. You must authorise your admission to hospital at least 48 hours before you go in. The medical aid needs to know so they can arrange your costs in the best way, and give you information that is relevant to how they will cover you hospital stay.
Once the medical aid authorises your hospital admission, your cover is subject to their rules, funding guides and clinical rules (protocols). You can find out more about their rules on their website facilities. There are some expenses you may incur while you are in hospital that the hospital benefit does not cover, e.g. private wards. Certain procedures, medicines or new technologies need extra authorisation while you are in hospital. Only medically appropriate hospital claims will be paid from the hospital benefit
Late Penalty Joiner
Late Joiner Penalties can be imposed on members over the age of 35. Depending on the number of years that they have not belonged to a medical aid, a Late Joiner Penalty will be added to the member’s monthly contribution every month for as long as the membership is active. It is worked out as a percentage of the contribution as shown in the next table and is based on the total number of years a member has not been on a medical aid since the age of 35 years.
No of years applicant was not a member of a medical aid since again 35 Penalty 1 – 4 years 1.05 x contribution ( 5%) 5 – 14 years 1.25 x contribution (25%) 15-24 years 1.5 x contribution (50%) 25 + years 1.75 x contribution (75%)