5 Questions you have about medical cover answered

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1.      What is the difference between a new generation option and a traditional option?

A traditional option (Foundation, Hospital, Progressive Flex, Progressive Flex Plus and Supreme options) consists of a number of stated benefits to which a rand value is linked.  For instance, a traditional option may allocate X amount for dentistry or acute medicines.  This basically means that the amount indicated is what you are covered for in that specific year for that item of healthcare.  Your benefits do not roll over to the next year if you don’t use them, and benefits for one area of treatment cannot be used for another area where you may want more benefits.

A new generation option on the other hand (Millennium and Millennium Select), also has stated benefits for certain items which are set and cannot be rolled over to the next year, but frees up a portion of your contributions (up to a maximum of 25%) for you to manage yourself.  These savings can be used on select areas of your healthcare and any amount left over at the end of the year is carried over to next year.  Savings are usually used for day-to-day benefits and services and in many cases, once used up require the member to pay for savings based cover out of their own pocket, called a Self Payment Gap, before they are able to access benefits for those items again as part of what is called an Above Threshold Benefit.

Both traditional and savings based options have their advantages and it is therefore important to discuss your choice with an accredited broker to make sure you choose the kind of option best suited to your specific healthcare needs.

2.     What are sub-limits?

In some cases the full amount allocated to a specific healthcare item (e.g.  preventative care) may have sub-limits included for categories of cover forming a part of that healthcare item. For example, you may have R 2 630 for preventative care, but only R1 584 of that can be used for oral contraception.  Both traditional and savings-based options can have sub-limits and it is important to understand your total and sub-limit benefit entitlement when choosing your healthcare option.

3.     Why do I need pre-authorisation?

For selected treatments, hospitalisation and certain conditions and procedures, the Scheme will ask you to obtain pre-authorisation before granting access to benefits.  This is in the best interests of the member and helps the Scheme to ensure that your benefits are being utilised correctly by providers and that they fall within your benefit entitlement. 

It is essential to get pre-authorisation either prior to, or in the case of an emergency, as soon as possible in order to ensure that you are covered for your healthcare item.  It is equally important to make sure that your pre-authorisation is updated with any additional items as soon as possible in order to avoid out-of-pocket expenses. 

4.     Who does the Scheme belong to and who makes money out of it?

In terms of the Medical Schemes Act, all medical schemes are not for profit entities and as such do not make a profit.  This means the Scheme has no shareholders or persons who gain from the income of the medical scheme.  The Scheme belongs to the members and they elect the Board of Trustees, which governs the operations of the Scheme.  The Board of Trustees Act in the interests of all the members and are accountable to them.

5.     What does an administrator do?

All medical schemes either self-administer or have an administrator who takes care of the day-to-day running of the Scheme’s interests.  This includes areas such as managing the membership, claims paying, client liaison and other functions of the Scheme.  The administrator reports to the Scheme on all aspects of their operations. Agility Health is Resolution Health’s administrator and managed care provider and, like all entities of this nature, is accredited by the Council for Medical Schemes to provide services to the Scheme.