Whenever we need to ask for pricing on something, we feel nervous because no one wants to appear uninformed for using the wrong words.You need to learn the correct language associated with medical aid schemes and terms used when requesting quotes for benefit plans.
This is when your medical aid covers part of a medical expense and you cover the remainder. The amount of the co-payment is related to the treatment or situation, and is dependent on your choice of option. Ask about co-payments when getting a quote to avoid unpleasant surprises when having to pay for medical emergencies.
PBMs stands for Prescribed Minimum Benefits. It is an important term when obtaining quotes. When looking at medical aids, there are certain healthcare benefits that you get, regardless of the option you have chosen. This means that there are certain diseases and treatments that must be covered by your medical aid by law. As such, PMBs should not be used as a marketing ploy; the medical scheme have to provide cover for these. However, the medical aid provider has the right to provide cover subject to the condition meeting the PMB requirement and subject to you following correct claiming procedure and being upfront about your medical conditions and treatment history upon applying for cover.
This is when a medical scheme needs time to assess your health situation and that of your dependants on your medical aid benefits plan. During the waiting period, you still pay your monthly membership fees, but you will only receive your benefits when the waiting period lapses. Of course, certain benefits such as your PMBs still apply. When you have a certain condition prior to joining a scheme, your waiting period might be longer than normal and claims for that condition might not be allowed.
The solvency ratio determines whether the medical scheme can pay the claims of its members or not. If the solvency ratio is low, they may not be able to pay. If it is high, it means that the scheme is more than capable of paying claims. The standard regulatory solvency ratio is 25%, so a scheme that is above the 25% will be able to pay members claims.
When a medical scheme shares free advice on medical issues and someone acts on the advice, there can be legal implications. Therefore, they will have a disclaimer to state that none of the medical statements can be used as a substitute for professional healthcare. As such, it is recommended that you always consult with a registered medical practitioner regarding any health condition rather than relying on information from a third party. This also applies to legal affairs. Consult with an attorney rather than simply trusting information provided by a third party source.
DSP means Designated Service Provider. This is the doctor, dentist, pharmacist, or other medical professional that is the first choice of that medical scheme. When getting a quote for a medical aid plan, ask for a list of the providers to make sure that the scheme’s DSPs are ones you trust. Ask for quotes from different medical schemes. This way, you can be sure that you select a medical aid that is perfectly suited to you. Do not be afraid to ask about any terminology. We welcome your questions and support informed decision-making.
