We’ll assist with all complaints and enquiries regarding your medical aid as far as the POPIA act allows. 

Frequently asked questions

Difference between a Medical Aid and Medical Insurance?

Medical Aid – More expensive

Medical Insurance – Much cheaper

Regulated by the Council of Medical  and Financial Services Board (FSCA)

Not regulated by the CMS.

Fall under Long term insurance act

Fall under short term insurance act

Cover from first moment that you are admitted to hospital.  Usually unlimited in hospital unless stated while you can be treated.

 

Read Small print carefully.

Cover to a certain amount per day for a certain period of time – usually 20 days for only a assured amount.

Medical scheme pays hospital directly

In some cases only pay in hospital for emergency cover.

Medical aid is about:

Your needs, risks, affordability and best value for money.

Underwriting when joining a Medical Scheme.

Any person can get 3 month general waiting period, a 12 month pre-existing exclusion or a late joiner penalty after age 35 joining a medical scheme.

3 Month waiting period

To maintain Solvency level. Regulation state it must be 25%

If you did not have cover on an registered SA Medical Scheme or did have a breakage between two Medical Schemes for more than 90 days.  You will get a 3 month general waiting period.  No cover at all for 3 months.  First put money into bank before you can start using it.

If you were on a registered Medical Scheme and did not have a break than more than 90 days between two Medical Schemes..  You can still get a 3 month waiting period, but you will be covered for PMB’s (Prescribe Minimum Benefit)  (ONLY emergency cover, life threatening ).  Go directly to emergency rooms and be admitted to hospital.

What is a PMB?

Prescribed Minimum Benefits (PMBs) are a set of predefined conditions that form part of South Africa’s Medical Schemes Act. With PMBs, anyone who is part of a medical scheme, no matter what medical aid plan they’re on, can receive treatment for 270 hospital-based and 27 chronic conditions, and the price of these will be covered in full. The aim of PMB cover is to ensure that the wellbeing and health of South African medical aid members is safeguarded, and that private healthcare is more affordable. PMBs also cover any kind of emergency treatment and include certain out-of-hospital treatments.

12 Month exclusion

Any person that were not on a registered SA Medical Scheme or were on a registered SA Medical Scheme for less than 1 year can get a 12 month exclusion for any pre-existing condition.  (Pregnancy included).  Nothing will be covered related the pre-existing condition for first year

Late Joiner Penalties. -Cross subsidisation, Young is carrying the old.

Any person can get a LJP after the age of 35 if they were not on a registered SA Medica Scheme.

Calculated  as follow:

Age minus 35 years.  Person must give proof then that they were on registered SA Medical Scheme by providing all previous SA Medical Scheme Membership Certificates and or a affidavit stating from when till when they were on a registered SA Medical Scheme.

1-4 years after 35 not on registered SA medical Scheme : 5% premium load on risk premium. (Savings excluded).

5-14 years after 35 not on registered SA Medical Scheme : 25 %premium load.

4-25 years after 35 not on registered SA Medical Scheme : 50% premium load.

More than 25 years :  75% premium load.

Medical Scheme Broker Commission

3% of your premium to a max of R98-85 + VATper month. Already included in your medical aid premium.

Broker can charge additional advice / admin fee.  For non Mooirivier Mediese Fondse clients.  R250 per hour.

When joining a scheme we look at:

1.Good hospitalisation

2.Out of hospital Cover

3.Chronic Cover

Hospitalisation

What percentage does the Medical Scheme pays in hospital.

100% the Medical Scheme tariff is not always 100%.  Specialist doctors can charge more than the Scheme rate if they are NOT contracted with that specific Medical Scheme.

What are the limitations in hospital?

Usually on cancer, organ transplant, dialysis, joint replacements and psychological treatment.

What is the pre admission Co-payments in hospital?

Can be on Dentistry, Endoscopic prosedures, Hernia, Joint replacements, MRI and CT-scans, depending on the Medical Scheme and plan tipe.

Out of hospital benefits

Traditional:  Day to day –  What you see is what you get.  What you don’t use you lose.

New generation:  Savings plan – What you don’t use you don’t lose.  Carried over to next year. 

Chronic Cover

Get two category’s

  • 27 PMB (Prescribe Minimum) Chronic conditions. Absolute necessary / life threatening.   Must be paid by all Medical Schemes.  Must meet the Medical Schemes criteria.  Medical Scheme will pay as per formulary and formulary price.  Must get chronic medication through a Designated Service Provider (DSP) to avoid big co-payments on chronic medication.
  • 42 NON PMB Chronic condition. Depending on what Medical Scheme and what plan tipe the Medical Scheme will state what they will pay. Also as per formulary and formulary price.

Fully accredited by the Council for Medical Schemes - ORG 3987, BR 25778
Authorised Financial Service Provider(FAIS) - FSP 43939

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