10 tips on reading your medical scheme’s benefit schedule

There are some basic things you need to know about your medical scheme. These include network hospitals, the medical scheme rate, and cancer treatment offered on your option before you might suddenly be confronted with huge co-payments.

Here are a few things you need to look out for:

Fund rate. Many new members look at the benefit schedule and see that a fund pays 100% of the fund rate for hospital procedures. They then assume that they are fully covered for whatever happens in a hospital. Not so. The Fund rate is an industry rate which has been negotiated between funds and the service provider (hospital, doctors and so forth).

The actual rate might be much higher, and often is especially when it comes to private doctors and hospitals not part of the preferred network or one of the designated service providers. Some schemes pay 200% of the fund rate, but the contributions will be higher.

Pre-authorisation. You need to get authorisation from your fund before you are admitted to hospital for any procedure. Find out about how to do this. If it is an emergency, the hospital or a relative must contact the fund as soon as possible, otherwise you might have to foot the bill yourself.

Beneficiary/family. If a principal member has dependants, they are all beneficiaries. Sometimes there are sub-limits in the benefit schedule per beneficiary and sometimes per family, which is the principal member and all his/her dependants together. So in the case of the latter, if one member has exhausted the total dental benefit for the family for the year, the others will have to pay cash until the benefits kick in again in the new benefit year.

Read: 20 claims medical schemes don’t have to pay for

In-hospital benefits. This might sound straightforward, but remember that this covers hospital accommodation, procedures in hospital, in-hospital doctors’ consultations, treatment by healthcare staff such as physiotherapists, psychiatrists, some surgical appliances (depending on your option), medication, scans and X-rays. Most schemes will only pay for a room in a general ward, and your benefits are option-specific. Make sure you know what they are.

Overall annual limit. This is the total amount for which you and your dependants will have cover for any treatment that is not a prescribed minimum benefit (of which there are 270). Although you may apply for ex-gratia payments if you exceed this amount, such as when several family members are in the same accident, for instance, the fund is not under a legal obligation to fund non-PMBs beyond the amount specified as an overall limit. Some funds specify that hospital cover is unlimited – however all funds carefully monitor high-cost cases in order to protect the interests of other members.

Read: Know your scheme's PMBs

Chronic illness benefit. There is a list of 26 chronic illnesses which all schemes have to cover treatment and medication for all their members. These are conditions such as asthma, diabetes and epilepsy. You have to register with your scheme for this benefit, but payment for these medications will not come out of your day-to-day benefits. Hospital plans also cover treatment for these conditions.

Network GPs, specialists and hospitals. These are hospitals and doctors who have made payment arrangements with your fund. That means if you use their services, there will be no co-payments for you to make.

Sub-limits. If you have a comprehensive medical scheme with day-to-day benefits, there may be certain amounts specified for things such as dental work or spectacles. Let’s say you have R8000 per year in your medical savings account and the dental sub-limit is R3500, you will have to make a co-payment if the bill is more than R3500m even if you have money in your savings account.

Fund medicine rate. That is the amount your scheme will pay for medication for a specific condition.

It is usually the lower average of generic medications. Generic medication is made once the patent has expired on the original medication it contains the same active ingredient as the original medication, but is usually much cheaper.

Oncology treatment. This is cancer treatment. Check carefully to see what you are covered for and whether there is a limited amount per beneficiary per year. Check whether it is only in-hospital treatment. This is often a rolling 12-month limit, and isn’t from January to December as most other benefits are.

Rand amounts vs. treatment days. For some treatments, such as psychiatric services and alcohol and drug dependency, schemes can either specify a fixed rand amount or a maximum number of days, if they do have this benefit at all.

Read more:

What you need to know about PMBs in 2016

14 quick facts on medical schemes in SA

What to consider when changing your medical scheme

References: The Council for Medical Schemes; Discovery Health; Nasmed Medical Scheme

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