It is important to know what you are buying when you sign up for medical aid. There are different options to suit individual or family needs. These options vary according to medical aid plans and every scheme has several plans to choose from. It is not just about price. It is also about benefits and this is where many South Africans fall short. They choose different medical aid options based on the monthly contributions without looking at the benefits of each plan. The pinch is felt when you need certain benefits which is not included on your plan and have to fork out cash for the medical bills.
Daily, Chronic and Hospital Options
There are three main options that you need to know about when it comes to medical aids. There is the daily or out-of-hospital cover, chronic medication cover and hospital cover. Each option has specific purposes to cater for all your needs. The limits allocated to each also varies so it is possible to exhaust the funds on one option and still have funds in another. Unfortunately you cannot transfer funds between these options.
The daily option, more correctly known as day-to-day or out-of-hospital cover, pays for the medical bills you accrue by visiting doctors and other health care professionals, at the pharmacy or tests and procedures when you are not hospitalised. It covers acute medication and some medical aid plans will even pay for vitamins and other supplements. In this day and age with medical aids facing more claims and a tough economic environment, the daily option has a very tight limit and is quickly exhausted if you frequently seek medical care.
The chronic option covers the cost of chronic medication. These are the drugs that you take for more than 6 months and sometimes for life. Depending on your plan, the chronic cover may also pay for regular monitoring for the chronic disease in question and other treatment options. Although there is a limit for the chronic option, if you have one of 25 serious ailments then a special rule known as the prescribed minimum benefits (PMBs) is applicable, and you will be covered for medication for the entire year.
The hospital option pays for all of your bills when you are hospitalised. This includes your hospital stay, doctors fees, surgery when necessary, lab tests and scans. Hospital options have a very large limit and some may be unlimited. With private hospital care being so expensive in South Africa, the hospital option is allocated the bulk of the cover on any plan. Some hospital plans pay above the medical aid rate (NHRPL – National Health Reference Price List rate) or you can opt to top up with gap cover for medical aid.
Types of Medical Aid Plans
Quite simply, most medical schemes have two types of plans – a full or comprehensive plan and a hospital only medical aid plan.
- The comprehensive medical aid plan has the daily, chronic and hospital cover.
- A hospital only medical aid plan as the name suggests is only for hospitalisation and has the chronic option included with the hospital option.
There are several options within each type of medical aid plan. As with any product or service, the more expensive options have more benefits. Some schemes have as many as 20 different plans and while this may seem excessive to the average consumer, the reality s that different plans suit different individuals and families. A younger healthier person without any chronic disease and a limited budget may opt for a hospital only medical aid with moderate limits. A middle aged couple with children may find that a comprehensive medical aid with very large limits are a better option.
However, at the end of the day it is all about money in this day and age. Fortunately medical schemes have now catered for the budget market by offering very cheap cover that has restrictions for certain clinics and hospitals only. Many South Africans do not look beyond their affordability and some opt for the cheapest plans even if they could afford better cover. Be aware that there is no single cheap medical aid in South Africa. All schemes offer just about the same plans with the same options and around the same price. It is therefor important that you look around for the best plan to suit your individual needs and budget. This is where the input of a medical aid broker can be invaluable.