Medical aid concepts
What is the difference between medical aid, health insurance, and gap cover?
Medical aid covers a wide range of healthcare services and is regulated by law. Health insurance usually offers limited, event-based cover, while gap cover is the bridge between what the medical aid pays and what providers charge. Have a look at our post for more details on the difference between medical aid, health insurance, and gap cover.
Do I need gap cover when I have medical aid?
Gap cover is optional, but it can help pay the difference between what your medical aid covers and what doctors or specialists charge, especially in hospital. Read our blog to better understand gap cover.
What is underwriting?
Underwriting is how we assess your health risk when you apply to join Medihelp – the likelihood that you may need medical treatment based on factors such as your health status and medical history. Based on your health profile, we may apply waiting periods before certain conditions are covered, or a late-joiner penalty if you haven’t been on medical aid before.
What is a late-joiner penalty
Late-joiner penalties apply if beneficiaries who have never been members of a medical scheme before, enrol for the first time, or if there were prolonged breaks in coverage at previous medical schemes.
What are prescribed minimum benefits (PMBs)?
Prescribed minimum benefits (PMBs) are conditions that all medical aids in South Africa must cover by law, except where underwriting applies. These include emergencies, certain chronic illnesses, and defined medical conditions.
What are generic medicines?
A generic medicine is a lower-cost version of a brand-name medicine that works the same way and gives the same medical results. It has the same active ingredients, strength, quality, and safety as the original medicine, so it can be used as an equal replacement.
When the patent on an original medicine expires, other companies can make the same medicine using the same active ingredients, strength, and dosage form – and it must be absorbed by the body in the same way. It is sold under a different name, but is held to the same regulatory standards as the original.
Choosing generic medicine can help you save money on your medical costs.
What are ICD-10 codes?
ICD-10 codes are used by doctors to show what condition you were treated for, so your medical aid can process the claim correctly. Always have this code ready when requesting approval or a referral.
What is a co-payment?
A co-payment is an amount you pay yourself when your medical aid does not cover the full cost of a treatment or service.
What is a medical emergency?
A medical emergency is something sudden and serious that needs immediate treatment to protect you from death, disability, or impairment. Without quick care, it could seriously affect how your body works, damage an organ, or even put your life at risk.
What is a medical savings account (MSA)?
A medical savings account (MSA) covers everyday medical costs. Here’s how it works:
- A percentage of your monthly contribution goes into your MSA (if you have chosen a plan with a savings account component. This amount varies depending on the savings plan)
- The full year’s amount is available from 1 January
- Claims are paid from your MSA first
- Once your MSA is used up, other benefits may apply (depends on your plan)
- Unused funds roll over and earn interest
What happens when my medical savings run out?
Once your savings are used up, some plans offer additional day-to-day benefits for you and your family. As a Medihelp member, you can view your available benefits on the Member Zone.