Deciphering medical aid speak

It can be rather daunting trying to understand the terms in your medical aid plan and all the detailed information about your benefits.

Medical schemes and the Council for Medical Schemes (CMS) use certain terms in reference to benefits. They can be tricky to fathom.

Here are some of the most frequently asked questions, as highlighted by the Bonitas Medical Fund call centre.

Prescribed Minimum Benefits (PMBs)

PMBs are confusing even to those in the medical industry, but simply put, it is a list of 26 chronic diseases and 270 treatments which have to be covered by all medical aid schemes as outlined in the Medical Schemes Act.

PMBs are in place to make sure all members have access to certain minimum health services, regardless of their benefit option. The aim is to provide members with continuous care to improve their health and well-being and to make healthcare more affordable.

Above Threshold Benefit

Medical schemes set an annual limit for day-to-day claims. Once you have reached this limit – or threshold – then your claims are paid from the “Above Threshold Benefit”.

The amount available depends on the plan you are on, as well as the number of dependants.

Day-to-day limits

Members and their dependants are given a pre-determined maximum amount of money for out-of-hospital expenses during a year.

There is a limit to what you can spend after which you move onto the above threshold benefit.

Pre-authorisation

Unless there is a medical emergency, members are required to obtain pre-authorisation from their schemes before being admitted to a hospital for a procedure.

If you do not organise pre-authorisation, the scheme can refuse to pay.

Quotes for procedures

Bonitas advises members to not only obtain pre-authorisation, but to also ask for a detailed quote from the hospital and medical practitioner prior to being admitted to hospital (if it’s not an emergency).

It means you can submit it to your medical aid ahead of the procedure to find out if co-payments will be required and if so, how much they are.

Co-payment

Medical practitioners and hospital often charge more than medical aid rates. This means medical schemes seldom cover the entire bill.

A co-payment refers to the outstanding portion of the account, for which you will be responsible.

A co-payment varies from one medical aid scheme to another and is sometimes not necessary if you use a designated service provider or network hospital.

The medical aid can pay from 100% to 300% of the medical aid tariffs, depending on the plan you are on.

ICD codes

This is a coding system developed by the World Health Organisation (WHO) that translates the written description of medical and health information into standard codes.

It means every medical treatment and diagnosis has a specific code – called an ICD 10 code.

These are important as it allows the scheme to identify the code of the healthcare service you require and to make sure payment is made.

The correct ICD code must be included on every claim to ensure you are paid for the correct benefit and t the healthcare practitioners are paid for their service.

Claim

After you have seen a doctor or been in hospital, you can either pay the bill directly and claim the amount back from your scheme or your doctor can submit the claim on your behalf.

Remember to ensure that all the correct information is on your claim, including your membership number and the ICD 10 code.

Chronic Medication

Is medicine prescribed by a medical practitioner for an uninterrupted period of at least three months. This medicine is used for a medical condition that appears on your scheme’s list of approved chronic conditions. Payment of chronic medication is usually a separate allowance on your medical aid plan.

Formulary

Medical Aids have a list of medicines on what they call their formulary – or list – that are recommended to treat different diseases. If you opt for medication not on the formulary there might be a co-payment.

Generic medicine

There are a number of generic medicines on the market that are cheaper than the original, patented brands however they contain the same active ingredients and are just as effective. Most medical schemes encourage the use of generic medicines to save costs and help you stretch your benefits. Check with your pharmacist.

Private healthcare in South Africa is not cheap and the best way to make the most of your medical aid or hospital plan is to understand what is and isn’t covered as well as the terms and conditions.

Make sure you get to grips with the various terms used by your scheme and your doctor and if you are unsure … ask!