South African Medical Aid is extremely unique from other countries in the fact that the said Medical Aid (insurer essentially) is ‘forced’ to cover the insured whether they want to or not (principle of open enrolment). The enabling legislation here is the ‘Medical Schemes Act 131 of 1998’. This said, make no mistake that Medical Aid is a legalised Pyramid scheme! The sick subsidise the healthy, simple as that. More healthy members means more money for sick members.
No Medical insurer may do the job of a Medical Aid in any way. E.g. let’s say ‘X’ Health insurance company offers an insurance policy that covers say, maternity fees to a Rand amount. The policyholder in this instance is bound by what the policy wording says to the letter so a premature birth or further unforeseen complications are highly unlikely to be covered as with a Medical Aid. Most importantly, the insurer also has to ordinarily refund the policyholder and not the provider, therefore the hospital/doctor would ordinarily require up-front payment from the patient. In minor instances this varies, but the point is there is nothing like Medical Aid, not in South Africa or any other country for that matter. We forget this as SA citizens. We have had many clients emigrating and asking us for cover similar to Medical Aid and besides NHS in UK which comes close, there is none.
The premiums/contributions are set out each year standard and they can’t be reduced or increased for anyone, no matter how low or high a risk they pose to the Medical Aid (Late-Joiner Penalties (LJP’s) are the only exception).
Lastly, the term Prescribed Minimum Benefit (PMB) is the most crucial term. Understand, it again ‘forces’ the Medical Aid to cover the costs related to diagnosis or treatment & care of:
- Any life-threatening emergency medical condition
- A defined set of 271 diagnostic treatment pairs
- 27 chronic conditions (Chronic Disease List (CDL) conditions).
The personalised Medical Aid quotation you receive via email will detail any potential Late-Joiner Penalties (LJP’s) or reduction in premium due to low income. Over the past years we have reduced the number of Medical Aids we work with and ended up with the following four that we trust with our client’s Medical Aid needs:
Pro’s – By a long long way, SA’s # 1 Medical Aid ito professional/efficient claims processing, COVID claims, PMB coverage, Expensive Cancer/Cardiovascular treatments, in-hospital dental, cochlear implants and all-round coverage. Feel free to stop reading now and simply request a Discovery Health quotation. 😊
Con’s – Dependents aged 21 and more get charged adult rates even if full-time studying or unemployed (Profmed & Medihelp have concessions). It’s annoying that out-hospital MRI/CT scan cover doesn’t apply to options without a savings component, meaning that the Core series is subject to PMB only.
1 – DISCOVERY HEALTH EXPLAINED (2022)
2 – NEW 2022 PRICES (EFF FROM 1 OCT 2022)
3 – DAY SURGERY NETWORK (2022)
5 – FREE SCREENING & PREVENTION GUIDE (2022)
6 – FREE INTERNATIONAL TRAVEL INSURANCE BENEFIT GUIDE (2022)
Pro’s – The more expensive ‘Associated’ or ‘Any’ Chronic benefit option choices offer hands down the best chronic formulary in SA. Pure hospital cover (Discovery equivalent of Core series) does enjoy out-hospital MRI/CT scan coverage.
Con’s – Momentum Health’s preferred PMB provider is the State as in the Government which is as good as saying ‘not covered’. Yes we are able to get around this a lot of the time but that is something quite serious to be aware of.
1 – MOMENTUM HEALTH EXPLAINED (2022)
2 – NEW 2022 PRICES (EFF FROM 1 SEP 2022)
4 – CHRONIC (ASSOC & ANY) GUIDE (2022)
5 – FREE CHECK-UPS ‘HEALTH PLATFORM’ GUIDE (2022)
6 – FREE INTERNATIONAL TRAVEL INSURANCE BENEFIT GUIDE (2022)
Pro’s – +-3% profit-share allocation for PPS members with PPS life insurance. Profmed has the best hospital network in SA. ‘Savvy’ and child rates could apply to adult dependents until age 27 & 11 months if full-time studying. Very strong PMB coverage.
Con’s – The worst out-hospital MRI/CT scan cover/in-hospital dental coverage, no out-hospital maternity visits on Pro-Active (Discovery Core series equivalent).
2 – NEW 2022 PRICES (EFF 1 APR 2022)
3 – DAY SURGERY NETWORK (2022)
Pro’s – Children age <=17 yrs & 11 mths are charged for a total of 2. Thereafter from 18yo until age 25y & 11 mths are charged per child at child rates. There are no questions asked by Medihelp or documents required for child rates to apply.
Con’s – Very poor in-hospital dental coverage same as Profmed and the same as Profmed, we are a little bit concerned at the high average age for members with Medihelp (Discovery and Momentum tend to attract the young and healthy).
2 – MEDIHELP 2022 PRICES (SINCE JAN)
2 – MEDIHELP OPTION NAME CHANGES
