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Medical Aid Schemes

Content Developed by JumpStartHandbook

There’s little time to think about money when you’re having a medical crisis! 

If you need a pair of glasses, you visit an optometrist. If you’re sick, you see a doctor. For an operation, you go to the hospital. But do you always have the money to pay there and then? Medical treatment can be incredibly pricey and hospitals even more so. And what about medical emergencies? 

The answer? A medical scheme. It’s a pool of funds you can draw on and use for your health. Every month you pay a certain amount of money into this fund and it gives you medical coverage (benefits), so that when you have to pay a doctor or go to the hospital, you’ll have money ‘saved’ that you can use. 

If, for example, you have R1 500 left in your fund at the end of the year because you’ve been pretty healthy, some medical schemes will add it onto next year’s balance or give it back to you. 

What is Medical Aid?

Medical aid is like insurance because even if you pay for it every month and don’t claim, you don’t get your money back. But some medical schemes have savings accounts for the more ordinary healthcare items. If money is left over, it can be carried over (accrued) to the next year or paid back to you. 

How Does A Medical Scheme Work? 

The money that you’ve ‘saved’ is put into your fund so that when you see a doctor, money is available to pay the bill. 

Some doctors will allow you to get treatment without paying them directly. In this case, the doctor's office will send a request to your medical scheme to tell them that you saw the doctor and that it cost, say, R200. The scheme then pays your doctor and subtracts the R200 from your fund. 

Remember: you are ultimately responsible for ensuring that your doctor is paid! 

Although most medical schemes will pay the doctor directly for the full amount and deduct it from your fund, some schemes need you to pay a portion of the bill. So if the bill is R200, you may need to pay R50 and your medical scheme will pay the rest. This also happens when you fill a prescription for medicine at a pharmacy or dispensary. 

Choosing A Medical Scheme 

A medical scheme must be registered with the Medical Schemes Council. If it isn’t registered, it’s either an illegal scheme or not a scheme at all. Medical schemes are not allowed to make profits, but because they compete with other schemes they offer different types of benefits to suit your needs. They charge different amounts depending on the types of benefits they offer.

By law, medical schemes are not allowed to charge you different amounts if you’re older, sicker or belong to a group that the scheme thinks is risky. 

Each type of scheme allows for different things and how much you pay depends on the scheme you choose. Your payments or contributions are made on a monthly basis and increase from time to time, usually annually. The range of benefits may change at the same time - but schemes have to obtain permission to charge more or change their benefits. 

  • Your choice of scheme will depend on things like: 
  •      • Your income: Many schemes offer low-priced options if you don’t earn a lot of money. 
  •      • Your job: Some trade unions or employers may require you to join certain schemes - but 
  •         you’ll probably have a choice of options on that scheme. 
  •      • Your general health: While a scheme can’t charge you more if you have health 
  •        problems, it is likely to impose waiting periods. Choose a scheme which offers good 
  •        benefits in the areas you need.

Visit www.medicalschemes.com for a list of registered medical schemes. 

What Types Of Schemes Are Available? 

Each medical scheme has special names for different schemes and each offers you different coverage. Some may pay all your bills; others may pay for hospital visits only. 

All schemes are obliged by law to pay for the treatment of certain diseases and medical emergencies. There are about 170 different diseases and 25 chronic conditions that schemes must pay for. 

While medical aid is like an account, it also allows you to pay for things that cost more than you have. An operation can cost as much as R50 000! Depending on your scheme, your medical scheme may pay the full amount or sometimes more - even though you’ve only paid monthly premiums worth, say, R3 000. 

  • Here are some examples: 
  •      • Fully comprehensive: this usually costs the most and will cover almost all of your 
  •        expenses in full. 
  •      • Hospital plan: this means that once you’re admitted to the hospital, everything is paid 
  •        for. But it doesn’t cover, for example, a visit to the doctor for a flu injection. 
  •      • Family plan: this option is for families where more than one person needs medical aid. 
  •        Dad might be the main (principal) member and Mom and kids, the dependents. A 
  •        dependent is a person on someone else’s medical aid; usually under the age of 21

At very least, everyone should be covered with a Hospital Plan. Imagine being in a car accident and you do not have suitable cover to pay for your medical bills at a suitable hospital. 

Frequently Asked Questions

• How do I select the best scheme for me? All medical schemes need to register with the Council for Medical Schemes. Visit www.medicalschemes.com or phone (012) 431 0500 for a list of medical schemes with contact details. Ask each to send you a package of information or arrange for a meeting with a consultant. 

• Can anyone join a medical scheme? Pretty much. The law says that a medical scheme can’t refuse membership to someone with a chronic illness like cancer or HIV/AIDS. But there will be waiting periods - a 3-month general waiting period and 12 months for existing conditions (conditions you already have when you join). 

• What isn’t covered by medical aid? Some medical schemes have restrictions or limitations and won’t cover certain treatment. So you can’t have a nose job and ask your medical scheme to pay for it, unless you need it for valid medical reasons. Before obtaining a membership, find out exactly what’s covered by the scheme.

• What role does my employer play in my medical aid contributions? Some companies pay a portion of employees’ medical aid. Ask your company whether or not this is included as part of your employment packag


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