The problem with comparing medical aid quotes is that the market resembles a jungle of different products and packages, and even after you have familiarized yourself with the jargon of the industry, you are still not completely sure whether you are comparing apples with apples, or not perhaps comparing bananas with oranges.
Some of the jargon explained
Prescribed minimum benefits (PMBs) – these are benefits that are guaranteed by the Medical Schemes Act, regardless of your medical plan or scheme, and include all serious, diagnosis-driven conditions, including conditions such as diabetes, asthma, cancer and HIV.
National Health Reference Price List (NHRPL) – this is the list of medical fees and rates recommended by the Council for Medical Schemes and published by the Department of Health annually. Some health practitioners charge NHRPL rates, but most charge in excess of these rates, some by a small percentage but others by as much as 300%. How this shortfall is dealt with, depends on a particular medical aid or plan: Some will offer 300% cover for higher membership premiums, some expect the member to pay the difference, while others have agreements in place with designated service providers who they will pay in full, provided the member makes use of these preferred health care practitioners.
A designated service provider – a health care practitioner who has an agreement with a medical scheme to provide medical services to its members at a fixed rate.
Personal medical savings account – an account set up by a medical scheme for use by a member of the scheme for health services not included under the prescribed minimum benefits (PMBs). Essentially, the member is saving for his or her own medical expenses which are not covered by the Medical Schemes Act. A positive balance in the personal medical savings account at the end of the year will be carried over to the following year.
Co-payment – the amount for which a member of a medical scheme is liable when the member chooses to use a practitioner other than a designated service provider. The member has to pay the difference between the amount stipulated in the rules of the medical scheme and the rate charged by the service provider.
Pre-authorisation – authorisation obtained from a medical scheme before undergoing a medical procedure; the medical scheme decides on the appropriateness of the procedure before granting permission for the member to undergo the procedure.
Day-to-day benefits – All benefits that are not part of in-hospital treatment, i.e., consultations, dentistry, optical examinations, etc.
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