Employee Benefits

Our Team > Our Services > Specialised Products > Service Providers > Forms > Learn about it

Learn about it: Healthcare

WHAT A MEDICAL AID DOES

Members’ contributions get paid in the Medical Aid to pay their claims

A medical aid is not-for-profit entity. The members of the medical aid pay contributions every month. All of these contributions are paid into the medical aid, which is essentially a pool of money owed by its members. This money is used to pay claims for health care services.

Medical aids operate on the idea of cross-subsidisation. By putting everyone’s money together, medical aids help to make private health care cover accessible.

back to top

HOW MEDICAL AIDS WORK

Every month medical aid members pay contributions into the medical aid… a pool of money owned by the members.

This money is used to pay claims for health care only.

The money paid by members who are healthy and have only a few claims is used to pay for claims of less healthy members who have many claims.

By putting everyone’s money together, medical aids help to make private health care cover accessible.

back to top

WHAT MEDICAL AIDS DO NOT COVER?

You should know that most medical aids will not pay or health carte services related to the following, except where a condition may form part of the prescribed minimum benefits

1. Cosmetic procedures

2. Otopasty for bat-ears, portwine stains and blepharoplasty (eyelid surgery)

3. Breast reductions and gynaecomastia

4. Obesity

5. Frail care

6. Infertility

7. Wilful self-induced illness or injury

8. Alcohol, drug or solvent abuse

9. Wilful and material participation in a violation of the law

10. Wilful participation in war, terrorist activity, riot, civil commotion, rebellion and insurrection

11. Experimental, unproven or unregistered treatment or practices

12. Where third party is legally responsible

13. CT colonoscopies and CT angiograms

back to top

WHAT IS A MEDICAL EMERGENCY?

A medical emergency is an event that involves the sudden, unexpected onset of a health condition that needs immediate medical or surgical treatment. Failure to provide this treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s life in jeopardy.

back to top

COVER FOR GOING TO CASUALTY?  

If you go to a casualty or an emergency room and you are not admitted to hospital, these costs will be paid from your day-to-day benefits. Some casualties charge a facility fee.

If you are admitted to the hospital from casualty, the medical aid will cover the costs of the casualty visit from your Hospital Benefit.

back to top

WHAT TO DO BEFORE YOU GO TO HOSPITAL

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

back to top

FOR THE MEDICAL AID TO PAY YOUR COSTS, THE MEDICAL AID MUST AUTHORISE YOUR ADMISSION BEFOREHAND  

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 cove you hospital stay.

back to top

COVER IS SUBJECT TO THE MEDICAL AID'S RULES  

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.

back to top

MEDICAL AIDS ONLY PAY FOR MEDICALLY APPROPRIATE HOSPITALISATION 

Only medically appropriate hospital claims will be paid from the hospital benefit

back to top

MEDICAL AIDS PAY YOUR HOSPITAL ACCOUNT FOR A GENERAL WARD

In general medical aids pay for your hospital stay in a general ward, not in a private ward. They pay the hospital account according to their agreement with the hospital.

back to top

MEDICAL AIDS WILL NOT ALWAYS COVER THE FULL COST OF YOUR HEALTH CARE PROFESSIONALS

Medical aids will not always cover the full cost of your health care professionals

Your health care professionals’ account is separate from the hospital accounts. Health care professionals’ accounts include specialist accounts and related accounts, which are accounts from, for example, a surgeon, anaesthetist, pathologist or radiologist.

Health care professionals are free to set their own rates. If they charge medical scheme rates, medical aids will pay them directly. If they charge more that the medical scheme rates, the medical aid will pay you. Then you will have to ensure you pay your health care professionals the full amount.

back to top

THE FOLLOWING 27 CHRONIC CONDITIONS KNOWN AS THE CHRONIC DISEASE LIST MUST BE COVERED BY ALL MEDICAL AIDS:

back to top

THE PRESCRIBED MINIMUM BENEFITS

All medical aids must provided cover or chronic conditions. This covers the diagnosis and management of your chronic condition.

The chronic illness benefit covers a limited number of diagnostic tests and consultations each year for the 27 conditions listed in the prescribed minimum benefits as per the list above.

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.

For consultation and tests in the prescribed minimum benefit treatment guidelines, they pay from chronic illness benefit as follows:

• Listed blood test and x-rays up to medical aid rate

• Any specialist consultation list in the treatment guidelines

• Four consultations a year at a general practitioner in the medical aid GP network. I you do not use a GP in the GP network, they will pay up to half of the charged rate

The consultations must have the appropriate diagnostic ICD-10 codes so they can identify them and pay them from the Chronic Illness Benefit

They pay claims from the day-to-day benefits if:

• They get claims without the relevant diagnostic ICD-10 codes

• You are not yet registered on the Chronic Illness Benefit

• You have exceeded the frequency limit on consultations or certain tests

back to top

HOW TO APPLY FOR CHRONIC ILLNESS COVER

You can only start claiming for chronic medicines once they have approved your cover. To apply for cover, follow these 4 steps:

• Step 1: Check the chronic conditions list above to see if they cover the condition

• Step 2: Get an application form

• Step 3: Complete the application form with your doctor and fax or post it to the medical aid or broker

• Step 4: Keep a copy of the completed forms for your records

They will review your application and tell you whether they approved your cover or not.

Access to the chronic illness benefit is subjected to certain clinical rules (they call these clinical entry criteria). They must first ask you for certain tests to confirm that you meet these criteria.

If your doctor diagnoses you with another chronic condition, please follow these same steps to apply.

back to top

THE CHRONIC ILLNESS BENEFIT COVERS ONLY MEDICINES

The chronic illness benefit covers only medicines that modify the disease, not supporting materials or therapies.

back to top

© 2011 FPM ADMINISTRATORS (PTY) LTD -  ESTABLISHED 1988  | Legal Notice | Contact Us

 Website by: tiltmann