Medical aid terms explained

Last updated on 12th December, 2017 at 05:05 pm

Deciding on the best medical aid option can be difficult, not least because some of the medical aid terms sound like they’re in a foreign language. We elaborate on the most common medical aid terms to help you.

Prescribed Minimum Benefits or PMBs
This is a list of 270 medical conditions (including HIV/AIDS, cancer and strokes) and 25 chronic conditions (such as diabetes, asthma and high blood pressure) for which all medical schemes have to provide diagnostic and treatment cover to a legislated standard of care, regardless of the benefit option that you’re on. You will have to register with your medical aid as a PMB user with the necessary supporting paperwork from your practitioner.

Out-of-hospital/day-to-day cover
As the terms suggest, these are your medical costs that do not involve a stay in hospital, such as visits to your GP or treatment and medicine for colds and other common ailments.

Pre-authorisation
This refers to the prior consent – in the form of a pre-authorisation number – that you require from your medical aid if you are going into hospital for a scheduled or pre-arranged procedure.

Formulary
This is the list of medicines that your medical aid has approved to treat certain diseases.

Co-payment
These are the out-of-pocket payments you would have to make for the shortfall between what your medical aid will cover and what your healthcare provider charges. Note: Healthcare providers are not obliged to charge medical aid rates, and their fees can be higher than what your scheme will cover, so it’s worthwhile finding out what this difference will be before your consultation. In certain situations, medical schemes will waive the co-payment if you don’t have another treatment option, other treatments haven’t worked or it’s an emergency.

Emergency
An emergency is defined as when immediate treatment by a healthcare professional is required to save your life or to prevent long-term health deficits.

DSP
Otherwise known as designated service providers, this is a network of healthcare providers with whom your medical aid has negotiated special rates. If you choose a provider outside this network on certain plans, you’ll be liable for the bill. Of course, there are always exceptions to the rule. For example, if you live in an area where there is no DSP nearby and you have to use a doctor outside of the network, your medical aid will cover those expenses.

ICD codes
This refers to the International Code of Diseases and Related Problems, which basically classifies every medical condition and diagnosis, so that your medical aid can identify and allocate the payment to the correct benefit. By law, your healthcare provider has to include the appropriate code on your bill.

Late-joiner penalty
In very simple terms, medical aids rely on a pool of healthy members to subsidise older and sicker members. Therefore your premiums are higher if you join a scheme at age 35 or older – you’re perceived as being a bigger risk – and have not been a member of one or more medical schemes before 1 April 2001, or have had a break in membership of a scheme for longer than three consecutive months since that date.

Threshold
If you have a savings account attached to your plan, your day-to-day medical expenses are paid out of that savings account up to a predetermined limit. Should you exhaust your savings account, you will be responsible for future bills, but when these bills reach a prescribed amount or threshold, then your medical aid takes over again to a certain limit.

Waiting period
When you join a medical aid for the first time or haven’t been a member for 90 days, you’ll be subjected to a waiting period before you can start claiming from your scheme. This is normally three months. If you have a pre-existing condition such as cancer or are wanting to claim maternity benefits, then you’ll have to wait 12 months.

NHRPL
The National Health Reference Price List (NHRPL) refers to tariffs and regulations related to certain healthcare products and services published by the Department of Health. All medical schemes are obliged to adhere to these guidelines by law.

By Nicci Botha