How South African Medical Schemes Work

  • July 24th, 2018

Medical schemes in South Africa Medical schemes in South Africa are non-profit organisations and as such your contributions are used towards administering the schemes to ultimately provide you with affordable medical treatments and to ensure that your medical bills are paid on time.

For you to enjoy medical cover for your treatments and medications, you need to make monthly contributions and submit the bills from the service providers according to the specification in the specific scheme’s rules and within four months from the date of treatment. In many instances, your scheme will pay the service providers directly, minimising your administrative load. In other instances, you are reimbursed according to the scheme’s policies and procedures for such.

Medical schemes in South Africa are regulated by the Medical Schemes Act of South Africa. Contribution rates and levels of benefits differ from one scheme to another. The contribution rates are also determined annually. Every scheme is managed by a board of trustees, of which 50% are members of the particular scheme.

All medical schemes in South Africa provide members with a set of prescribed minimum benefits known as PMBs to cover emergency conditions, 27 chronic conditions, and 270 life-threating or serious conditions. All the schemes in South Africa provide cover for the above.

Keep in mind that medical aids normally specify which service providers may be used for PMB treatments. Such providers are known as designated service providers. Should you use another service provider not forming part of their network of service providers, the medical aid can require that you make a co-payment unless you had no other choice than to use the particular provider because it was a bona fide emergency situation.

Many people do not belong to one of the many medical schemes in South Africa because they mistakenly believe that they will need to pay more because they are old or have pre-existing conditions upon joining one of the medical aids. The truth is that a medical aid cannot base its contribution rates on the member’s risk profile in terms of age or disease. However, late joining penalties are still valid, but such penalties are not related to the risk posed by the state of health, the frequency of usage, or age.

Why join?

Even if you have never been seriously ill, there is always the risk of contracting a life-threatening condition or being injured, thus requiring extensive medical care. You can make use of the public healthcare system which but due to many factors this system is overloaded and you cannot be guaranteed of the required standard of care for your particular condition.

The benefits of joining one of the reputable medical schemes in South Africa, such as Medshield, include:

  • Cover for expensive treatments, which you may otherwise not have been able to afford;
  • Cover for hospitalisation upon pre-authorisation;
  • Peace of mind associated with knowing that when you need medical care, you have access to it and you do not have to first save up before being able to get the required care; and Ensuring affordability of medical care

View our range of benefits and call us for more information on how to become a member of Medshield.

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