Deciphering Medical Aid Terms

Trying to understand medical aid terminology is enough to send you to the emergency room! It can get a little complicated and difficult to understand, a rather daunting feeling at the end of the day.

Between the Council for Medical Schemes (CMS) and the medical schemes themselves, they use specific terminology to describe the benefits offered in each of their medical aid plans.


Let’s decipher some of the most confusing terms:

1. Claim
Some doctors submit claims directly to the medical aid on your behalf, and others require you to settle the bill yourself and then claim back from the medical aid. The claim sent to the medical aid needs to have all the correct information on it like the ICD 10 code and your scheme membership number.

2. ICD 10 Codes
These are codes developed by the World Health Organisation to describe medical conditions. Every diagnosis and treatment have their own unique codes. Medical schemes require these codes to make sure they pay for your treatment are paid for from the correct benefit.

3. PMBs
PMBs are Prescribed Minimum Benefits. The Medical Schemes Act has outlined a list of 270 treatments and 26 chronic diseases that legally have to be covered by every medical aid scheme. These benefits ensure that no matter which benefit option you are on; you will have access to the minimum available health services.

The main aim of PMBs is to ensure that all members receive continuous medical care that will in turn help to improve their health at an affordable fee.

4. Day-to-Day Limits
Medical aids give members and any dependents they may have a maximum amount of funds for any out-of-hospital expenses throughout the year. This limit is known as a day-to-day limit. Once you reach the limit of this pre-determined amount, you move into what is called an Above Threshold Benefit.

5. Above Threshold Benefits
Once you have reached the limit on your day-to-day benefits, you enter into what is called an Above Threshold Benefit. These amount of fund available in this benefit will depend on your medical aid plan and number of dependents you have.

6. Pre-Authorisation
In the case where you need to be admitted into a hospital, except for an emergency, you are required by your medical aid to request pre-authorisation. This means that the medical aid needs to authorise you that they will pay for your treatment and hospital stay. If you do not get the pre-authorisation, the medical aid can refuse to cover any of the costs.

7. Co-Payment
Sometimes medical aid schemes do not cover the full cost of treatment if the service provider charges more than medical aid rates. Medical aid rates refer to the amount that your scheme is prepared to pay for a particular treatment. Where there is a shortfall with what they are prepared to cover, you will be required to pay the balance. This is known as a co-payment.

Depending on which plan you are covered with, the scheme can pay anywhere from 100% of medical aid tariffs up to 300%. Co-payments can vary depending on the scheme and which network hospital or service provider you use.

8. Generic Medicine
Generic medicines are cheaper alternatives to patented medicines on the market. These medicines contain the same active ingredients as the originals and are as effective in treating your condition. Opting for generic medicines can help you save funds in your medical aid to stretch them further. For this reason, many medical encourage the use of generics.

9. Chronic Medication
These medicines are classified as a prescribed medication for uninterrupted use over three months or longer. They are used to treat medical conditions listed on your scheme’s approved chronic conditions. Funds for chronic medications are often separate from your day-to-day allowance.

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