Considering medical aid? What is covered?

Are you considering taking out one of the many medical aid schemes in South Africa? If so, you will need to look carefully at each option to find the one most suited to your needs. To decide which one will meet your needs, you will have to look at what is covered and what is excluded. If you are not sure what to look for or what is covered in general by many of the best medical aids in South Africa, read the list outlined below for more information.

General practitioners and specialists

Many medical aid schemes in South Africa offer coverage for GP visits and specialist visits. This is fantastic for people with families where children need to see the doctor for sicknesses, and for those who feel that they need to see a doctor on a regular basis.

These services might not be covered completely by your medical aid, which means that you will have to make a co-payment of around R100 per visit. Specialist visits will have to be approved by your medical aid and if they deem it necessary, you might have to pay a little too, depending on what type of coverage you have. Being able to visit a GP at any time is highly beneficial as you will be able to address any medical issues as soon as possible and without breaking the bank.

Psychiatric treatment

Psychiatric treatment is rarely easy to deal with, and some medical aids do not cover it. A psychiatric visit includes seeing a psychologist, a psychiatrist or admission to a facility to help with treating a mental health disorder or other issues you might be facing.

Some medical aid schemes are limited in their cover, such as only covering a three-day visit and having a set amount of psychiatric visit allotted per member per year. It is important to find out your chosen provider’s offerings, especially if anyone in your family has mental health disorders. Depression and anxiety may not be covered by every provider, so if you have these conditions find out which ones offer this coverage before making a decision.

Prescribed Minimum Benefits (PMBs)

PMBs are illnesses that all medical aid schemes in South Africa are legally required to cover. These PMBs include any emergency medical condition, a set list of 270 medical conditions and 25 chronic conditions.

When a doctor decides whether a condition is a PMB or not, they will look only at the symptoms and not at any other factors. This is a diagnosis based approach, and once the diagnosis has been made, the appropriate treatment can be decided upon. The doctor will also decide on what hospital the patient should be treated at or whether it is able to be treated as an outpatient case. All medical aids offer cover for these conditions, so if you have one you will be covered.

Hospitalisation

Medicines used in hospital, surgical procedures in doctor’s rooms and PMBs are all part of the hospitalisation cover offered by the many medical aid schemes in South Africa. If you have an emergency hospitalisation, your medical aid will also cover this, which is great news for those who might have motorbikes or who could be hospitalised due to their occupation.

Unfortunately, cosmetic surgery such as breast augmentations, ‘tummy tucks’, liposuction and other procedures in this vein are not covered by many medical aids. This  means that you will have to pay for these procedures out of your own pocket. This can be highly expensive, so it is best to carefully consider these procedures before moving forward with them.

Dentistry procedures

Some medical aids do not offer dentistry as a benefit, but you will find that many do offer some form of cover. This could be in the form of one to three basic checkups per year, six fillings a year and two tooth extractions a year.

Dentistry is a highly important benefit to look for in a medical aid scheme, as your teeth are important to your health and wellbeing. Not being able to have them properly cleaned or seen to when there is an issue can be detrimental to your health, and dental costs can become exorbitant if you are not covered for them. When you are comparing the best medical aids in South Africa, be sure to look out for their dentistry benefits.

Weigh out the benefits

Once you have found out exactly what your medical aid scheme covers, you will need to weigh out the benefits to see if they match your needs. If you need regular GP or specialist visits, then you will need to look for a provider that offers these with affordable copayments. PMBs are covered by all medical aid schemes in South Africa, and a set list of chronic conditions are included in these. You will need to ask the different providers about what they do not cover, which will help to make the final decision on a medical aid that is right for you.