Navigating the world of medical aid and gap cover can be overwhelming due to the complex terminology used. To help you make informed decisions about your healthcare coverage, we’ve compiled a glossary of essential terms you’ll encounter when reviewing medical plans.
1. Medical Savings Account (MSA)
A portion of your monthly medical aid contribution is placed in a Medical Savings Account (MSA), which you can use for day-to-day medical expenses like GP visits, prescriptions, and over-the-counter medications. However, if you’re on a hospital plan only (where coverage is limited to in-hospital care), an MSA does not apply. Instead, you will be responsible for any out-of-hospital expenses, including doctor visits and chronic medication costs.
2. Co-payment
This is the amount you pay out of pocket for medical services. Co-payments can apply to various treatments, especially when using healthcare providers outside of your plan’s network or when opting for services that exceed your medical aid’s coverage.
3. Designated Service Provider (DSP)
A DSP is a healthcare provider or facility that has an agreement with your medical aid scheme to provide services at negotiated rates. Using a DSP can help you avoid unnecessary out-of-pocket expenses.
4. Prescribed Minimum Benefits (PMBs)
These are a set of 270 medical conditions that your medical aid scheme is legally required to cover, including emergency medical conditions, maternity care, and chronic conditions.
5. Chronic Disease List (CDL)
This list includes 27 chronic conditions that are eligible for treatment under the PMBs. Medical aids are required to cover the treatment of these conditions as part of their minimum offering.
6. Gap Cover
Gap cover is a supplementary product that helps cover the shortfall between what your medical aid pays and what healthcare providers charge, especially for hospital procedures. It ensures you’re not left with unexpected bills for procedures, specialists, or treatments that exceed your medical aid’s rates.
7. Waiting Periods
When you join a new medical aid plan, certain waiting periods might apply, ranging from three months for general coverage to 12 months for pre-existing conditions.
8. Self-payment Gap
This occurs when you have used up your MSA, and your medical aid has not yet reached its threshold for full coverage. During this time, you’ll need to pay for medical expenses out of pocket.
9. Scheme Rate
The rate at which your medical aid reimburses healthcare providers for specific services. If a healthcare provider charges more than the scheme rate, you may need to cover the difference.
10. Sub-limit
Some medical aids have sub-limits, which cap the amount they will pay for specific services or treatments, such as surgeries or prosthetics. You’ll be responsible for any costs above these limits.
By understanding these terms, you’ll be better prepared to choose a plan that works for you and avoid unexpected medical costs. If you’re uncertain about any of these terms or need more information on what your medical aid covers, reach out to your insurance provider for clarity.
