What is a Medical Scheme?

Let’s face facts: the cost of private medical treatment in South Africa is out of reach for most ordinary citizens. The only way in which to ensure quality medical attention is to become a member of a medical scheme. What is a medical scheme though?

The only alternative is to depend upon the overburdened, under-funded public health system that is already struggling to cope with a crippling demand. So: what is a medical scheme?

What is a medical scheme

The short answer is that medical schemes are non-profit organizations that enable their members to gain access to private health care facilities and practitioners in exchange for a monthly contribution.

The idea underpinning the schemes is that the young subsidize the old, and the healthy subsidize the ill members of the medical aid.

What is medical scheme in South Africa?

Every medical aid must be registered with the Council for Medical Schemes otherwise they do not qualify as proper medical schemes. So beware! There are many short-term insurance products called health insurance options which are NOT medical aids.

What is a medical scheme

Far from it. The products from these companies only provide insurance for hospital-related costs, such as loss of income, groceries, transport and so on. The payouts do not relate at all to actual medical expenses, such as specialist bills, hospital bills, and medication.

There are several medical aids in South Africa – possibly more than are needed. You can see the full current list of registered medical schemes here.

Medical schemes are divided into two groups: restricted schemes and open schemes. Restricted medical aids are open to members of a certain company or a certain industry only. For example, Bankmed is for workers in the banking industry only. And the Anglo Medical Scheme is for Anglo American employees and retirees only. Open schemes, on the other hand, are for anyone who can afford to pay the premiums. Some of these include Discovery Health, Selfmed, Medihelp, Bonitas and Genesis.

What is a medical scheme option?

Every medical scheme essentially offers two types of medical aid plans. Firstly, there is comprehensive-type medical cover which includes a savings account so that the members’ expenses are covered, even medication, dental visits and so on. Admittedly, medical savings accounts can run out, and this is where gap cover can be useful.

Secondly, medical aids offer basic cover aimed at hospital stays and covering Prescribed Minimum Benefits (PMBs). So for instance Genesis Medical Aid offers four health plans in total. Two of these are hospital plans while the other two are comprehensive medical plans.

Discovery Health is the flagship medical aid in South Africa. It is huge and extremely powerful in terms of the reserves it holds. In addition, it has an extremely rewarding rewards scheme attached, called Vitality. You can actually profit from your medical aid if you manage your Vitality stats properly by looking after your health.

It’s time to act. Get a comparative quote below to find out what is a medical scheme and join up.

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Medical schemes operating in South Africa are strictly controlled by the Council for Medical Schemes and they have to comply with a host of criteria that are vigorously policed. Here are the most important of those criteria:

• The scheme must be solvent. In fact, the law requires medical schemes to retain a minimum of twenty-five percent of all member contributions in reserve. This rule has been put in place to ensure that schemes are able to pay claims and to honor their promises to their members.
• No open scheme (medical schemes that are open to the general public) may discriminate against any group or person.
• At least half of the members of the managing board of any medical scheme must be members of that scheme. Remember: nobody is allowed to belong to more than one medical scheme at any given time; so this is a measure of faith that must be shown by the board members.

How to choose a medical aid scheme

Medical aid plans are costly and it is certainly worthwhile to conduct some research before choosing a specific plan. Here are some of the factors you should think about when evaluating the different plans on offer:

• You have to study the benefits offered by each plan very carefully. Some plans have severe limits and you need to be fully conversant with the terms and conditions. If you have questions you need to ask the scheme for answers, preferably in writing, before making any decisions.
• It is generally best to only consider plans that are flexible. That means that you must have the ability to upgrade or even downgrade your benefits as your circumstances change.
• Many employers offer medical scheme benefits as part of their remuneration packages. This may be problematic for new employees that are already members of another scheme. You have the right to negotiate and there is no law compelling anybody to become a member of any specific scheme.
• Most people are concerned about the cost of medical cover. However, the cost of a specific plan should never be the deciding factor. It is the needs of the family that should be the most important consideration. Far too many people view medical aid membership as a costly expense instead of as an investment in continued health. Membership of a medical scheme should be seen as a very high priority.
• You have to be aware of your rights. Medical schemes are strictly controlled and must, for example, provide full and unconditional cover for approximately three hundred conditions defined in the Minimum Benefits list. Some schemes require members to make use of specific networks of service providers and if this is not acceptable it may be best to rather consider another scheme that does not impose such limits and conditions.

Is it truly important to join a medical scheme?

Yes. Unequivocally! Get the very best medical cover that you can afford. If you fail to do so, you will be dependent upon the overburdened, under-staffed and under-funded public health system. You will not be able to choose the medical practitioner or facility of your choice. You will be subjected to long waiting periods and you will have to accept the treatment options presented to you. That’s why it is important to know what a medical scheme is and join one right away. © Medical Aid Plan

Medical aid quote will include options to suit your pocket. Please ensure that the cover you select is exactly what you need and that you understand exactly what insurance you are buying. Do not hesitate to ask questions about the medical aid or hospital cover you choose.