What is a medical scheme?
"Medical scheme" is the legal term for a company that offers medical aid. Most schemes have a variety of plans (also called options). A hospital plan will cover your costs when you're admitted to hospital, while a more comprehensive option will also pay for out-of-hospital expenses such as doctor's visits, chronic medicine, dental work and glasses. The cost and extent of cover vary from plan to plan and from scheme to scheme. Some of South Africa's biggest medical schemes are Bonitas, Discovery Health, Momentum Health and Fedhealth.
What are the different types of benefits?
- Prescribed Minimum Benefits (PMBs)
By law, all medical schemes are obliged to pay for specific chronic and emergency conditions with no co-payments or waiting periods (with some exceptions.) These prescribed minimum benefits include hospitalisation during pregnancy.
- Hospital benefits
Your hospital benefits will cover your overnight stay in hospital (known as "maternity confinement"), as well as the cost of your baby's delivery, blood tests while in hospital and perhaps even medicine to take home. Some schemes will also cover home births and birth pool hire from your hospital benefits. Be warned: some plans require a co-payment for elective caesareans, while others won't cover c-sections at all.
Read more: Your birth options
- Out-of-hospital benefits
Out-of-hospital or day-to-day benefits cover consultations and treatments not connected to an overnight stay in hospital. These benefits are limited to an overall amount or to a specific number of consultations per year. Some plans will pay your out-of-hospital expenses from a medical savings account (MSA), which consists of a portion of your monthly premiums that is available upfront. When your savings run out, you may have to pay for your own day-to-day expenses for the rest of the year, though some plans do have extra benefits that kick in once your savings have dried up. If you have savings left at the end of the year, it carries over to the next year.
- Maternity benefits
Many schemes offer specific maternity benefits, like a certain amount of antenatal consultations, ultrasound scans, blood tests and perhaps even antenatal classes. But look carefully at where these benefits come from and how it will impact the rest of your out-of-hospital limits.
For example, your family may be limited to nine specialist consultations per year. If your maternity benefits include six antenatal consultations and those visits are subject to your overall limit, your entire family will be left with only three more visits to another specialist (such as your children's paediatrician). In this case, your maternity "benefits" are in fact maternity "limits".
However, there are some schemes who offer maternity benefits on top of existing day-to-day limits. In these cases, your antenatal visits and blood tests won't affect the rest of your family's cover for the year. Some plans also offer extra benefits once you've reached your day-to-day limits, like extra visits to a gynaecologist or paediatrician.
You might only have access to maternity benefits once you've registered with your scheme's maternity programme, so make sure you're covered by letting your scheme know you're pregnant. And do make sure that you are in fact covered for specialists: some plans only cover GPs and midwives.
- Maternity programmes
Your scheme's maternity programme may come with pregnancy advice, support and complimentary baby hampers. Many schemes give these freebies to all their pregnant members, while others only make it available on the more expensive options. Some schemes link their maternity programmes to paid products like Discovery Vitality or Momentum's Multiply Premier.
What is the difference between "full cover" and "100% cover"?
Each medical scheme has its own predetermined rates for specific treatments and procedures. These are called the medical scheme tariffs (MST) or medical scheme rates (MSR). The schemes use these rates to work out how much they pay out.
If your medical scheme promises to pay "100%", it doesn't mean they'll pay the full cost. It means they'll pay 100% of the scheme tariff. For example, say your gynaecologist charges R700 for an antenatal consultation, but the scheme's tariff is R350. If you have "full cover", they will pay the entire R700 bill. If they cover 100%, they'll only pay R350 - and you have to pay the rest.
It's common for private specialists to charge 300% or more of the scheme rate, which will leave you with an enormous bill by the end of your pregnancy! To prevent this, you can pick a doctor that charges scheme rates, use a doctor and hospital in your scheme's network, or get medical gap cover to pay the shortfall.
Read more: Surviving the self-payment gap
How can I make sure I'm covered in full?
- Hospital and specialist networks
Most medical schemes have signed contracts with specific hospitals and medical professionals. These service providers form part of the scheme's network. Usually, if you use a service provider within the network, you are covered in full. If you want to use somebody outside the network, you'll either have partial cover, or no cover at all. Some plans only allow you to use the network, for a lower monthly premium.
- Gap cover
Gap cover is a great option if you want to use private hospitals and specialists. But beware: most gap cover plans have a 10-12-month waiting period for pregnancies. This means that you'll have to sign up a couple of months before you even fall pregnant.
What are waiting periods?
When you change schemes or join a medical scheme for the very first time, you may be subject to a waiting period. During this time you will pay your premium, but have no access to the benefits (other than PMBs). Waiting periods usually apply to pregnancy, so if you haven't already joined a scheme by the time you fall pregnant, you probably won't be covered for childbirth.
Read more: Which medical aid is the best one for you?
Read more: Medical aid: Not covered?
What medical aid benefit do you prefer? Let us know at email@example.com.