Frequently Asked Questions about Medical Schemes

Jun 26, 2017 | Blog

What is the difference between my Risk and Savings contributions?

The Risk contribution provides the member with cover for in-hospital benefits, chronic medication, emergency transportation and so forth.

The Savings contribution is a percentage of your total monthly contribution and the member cannot request to change the percentage.  It may also not be more than 25% of the total contribution. The funds are used to pay for day-to-day expenses such as doctor’s consultations, prescribed medication, radiology and pathology.

Do I earn interest on my Savings?

Yes, you do receive a very small amount of interest on your Savings.

Is the Savings available upfront? When can I start using the Savings?

If you have been accepted on the medical scheme with no waiting periods you can use the savings on the 1st day of the month you join the scheme.  However, if you have a 3 month’s general waiting period imposed on your membership, you may not claim from savings as no cover is provided.

There are schemes where the total annual savings is not available upfront, only a portion at a time.  However, most schemes do make the savings available upfront.  Remember that a medical scheme benefit year is January to December.

What happens to my Savings if there is still money left at the end of the year?

All credit is carried over to the new year.  You never lose the money. It is important to note that accumulated savings cannot be paid to member while still on the scheme, irrespective of which scheme you are on.

What happens to my savings if I move to another scheme?

If you have a credit in your savings, it will be transferred to the new scheme should the option you join have a savings facility.  This will however only be done after +- 4 months as all claims have to be processed and paid. Remember that providers have 3 months to submit claims.

If you move to a scheme that does not have a savings facility the accumulated savings will be paid to you, but also only after 4 months.

Should you have used all your savings and you resign from the scheme during the year, you will owe the scheme money as it was effectively lent to you. It is extremely important to remember that should you owe the scheme money and do not pay it, you will at no stage be allowed to join that scheme again until the debt is settled.

If there are co-payments or deductibles on my option, how and where do I pay?

Co-payments are paid at the service provider, whether it is the hospital or for instance the radiologist.  If you have Gap and Co-Pay cover these payments can be claimed and the insurer will refund you.  Note that the co-pay and deductible amounts differ from scheme to scheme and options.

If waiting periods are imposed on my membership of a medical scheme can I stay on my old scheme for that period?

It is illegal to be on two schemes at the same time.  You have to be withdrawn from your previous scheme before your membership of the new scheme will be activated. Remember that you have to give a calendar month notice.

Can I add my brother or sister’s children to my membership?

You can only arrange cover for them if you are their legal guardian, in other word you have all the legal documents proving guardianship.

Can I add my grandchild to my membership?

You can only register a grandchild as a dependant if you are the legal guardian.

When can I change my option?

Option changes are allowed at the end of the year, effective 1 January annually. We recommend that you contact us in October to obtain all information of the products for the following year and for your instruction to be submitted.

If I change to another scheme will I have waiting periods and exclusions?

Yes, your application will be underwritten.  What this means is that a 3 month’s general waiting period or 12 month condition specific exclusions can be imposed, depending on the time frames of previous medical scheme cover.

What is Prescribed Minimum Benefits (PMB)?

PMB’s are a list of defined conditions and procedures which have to be covered by all schemes, irrespective of the option you are on.  There are 271 PMB conditions which are listed in the Medical Schemes Act, and 26 PMB chronic conditions.  All PMS’s have to be covered at cost, although some schemes do require that the member receives treatment at a DSP.

What is a Designated Service Provider (DSP)?

A DSP is a healthcare provider or group of providers who have been selected by a medical scheme to provide members with the diagnosis, treatment and care in respect of medical conditions, including PMB conditions. If the scheme specifies that treatment is only covered at a DSP and the member voluntarily uses a non-DSP, there will generally be a co-payment.

Can I join a medical scheme if I am already pregnant?

Yes, you can, but no expenses regarding the pregnancy or confinement will be covered as it will be underwritten as a pre-existing condition and excluded for 12 months.

The baby will be covered from birth, as long as you register the baby as a dependant on your medical scheme, within 30 days of birth.

What is formulary medication?

Medical schemes have a formulary of medication for acute as well as chronic medication.  Most of the medication on the lists is generic medication and if the member requires non-generic medication there will be a co-payment. We recommend that you ask your doctor to prescribe medication which is on the formulary list.

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