Frequently Asked Questions

What is the difference between my Risk premium and Savings premium?

The Risk premium is the portion of your monthly premium that is used by the medical scheme to pay for all benefits (Hospitalisation, Chronic Medication, MRI & CT scans etc.) over and above out-of-Hospital benefits that is subject to your available Savings.

The Savings premium is a percentage of your total monthly premium and it is a fixed amount. According to legislation the premium may not exceed 25% of the total annual premium.

Your total monthly premium is calculated by adding the Risk premium and Savings premium together.

Do I earn interest on my Savings?

Yes, you do receive a very small amount of interest on your Savings.

When can I start using my Savings and is it available upfront or monthly?

If you don’t have a 3 month general waiting period when joining a medical scheme, you can start using your Savings from your inception / start date. The Savings is available immediately and is pro-rated. If you however have a 3 month general waiting period, you will only be allowed to make use of your Savings once that waiting period has expired.

What happens to my Savings if it is not depleted by the 31st December?

Should there be a positive Savings amount by the 31st December, that Savings amount will be carried over to the following year and added to the following years Savings. Your Savings will then accumulate year on year.

Can I request that the Savings is paid out to me at the end of the year?

Unfortunately not. The only way that you can have the savings paid out to you is if you resign from the medical scheme and you don’t join a new medical scheme, or if you change to or join a Hospital Plan only. The savings will then be paid to you after 4 month’s and the reason for this, is that you have 3 month’s to submit a claim before it is stale. The scheme wants to make sure that there are no late claims to be paid and processed. Should you move to another medical scheme and the option you join also has a savings component, you have to request that the savings gets transferred to your new scheme and option according to legislation.

What happens if my Savings is depleted and I change medical schemes or cancel my membership during the year?

Due to the fact that the Savings is pro-rated and available upfront, the scheme will request that you pay the outstanding balance back to them. An example of this will be as follows: Your Savings premium is R500, which gives you an annual Savings amount of R6 000. If you resign (cancel) your medical scheme, effective from the 30th June and your Savings is depleted, you will have to pay R3 000 back to the medical scheme (R500 x 6 month’s remaining for the year).

What does 100% of Scheme Tariff / Rate mean?

This is the tariff / rate at which a medical scheme will pay service providers – specialists, anaesthetists, physiotherapy, oncologists etc. We refer to this as the “normal medical scheme rate” or like many years ago the “contracted in rate”. There used to be a guideline for these tariff’s, known as the National Health Reference Price List (NHRPL), but that no longer exists. Medical practitioners still however use it as a guideline. This means that if you have a procedure in theatre in Hospital and the specialist and anaesthetist charges you more than that 100% tariff, you will be liable for the difference and that is where GapCover becomes very important. An example of this will be as follows: The specialist charges R30 000 for the procedure (which is 300% of tariff) and the scheme only pays R10 000 (which is 100% of tariff). The balance of R20 000 will be for your own account.

Can I negotiate tariffs / rates with the specialist and anaesthetist?

Yes, you must definitely do that. You can also contact your scheme to provide you with a specialist’s name and contact details who is contracted to that scheme and who charges the same tariff / rate at what the scheme pays. The problem however comes in when you want to use a specific specialist (for any specific reason) and that specialist does not charge the scheme tariff / rate or does not have a payment arrangement contract with your medical scheme. It is then the member’s choice to make use of such specialist and pay the difference in tariff / rate charged or claim it from GapCover.

What is a co-payment and how and when do I pay it?

A co-payment is an upfront payment you need to make at the Hospital, Day Clinic or Radiologist (MRI & CT scans) for a specific treatment, before admission and before treatment can commence. This co-payment can be claimed back from GapCover, should your GapCover cover co-payments. The amount of the co-payment payable varies, depending on the procedure, scheme and option.

Can I belong to more than one medical scheme at the same time?

No, this is illegal. You will have to resign from your current scheme and join the new scheme from the 1st of the following month.

Can my cousin or grandchildren be added to my membership as a dependant?

Yes, but only if you have legal documentation (court papers) confirming that you are the guardian parent(s).

Can a child / minor join a scheme in his / her own capacity?

Yes, but he / she will pay the principal member premium.

Can anybody be the payee of the monthly premium or must it be the member?

No, anybody (third party) can pay the monthly premium.

Who qualifies as a dependant?

The main member’s spouse / partner and children. All immediate family (mother, father, brother, and sister) and a child who is dependent upon the member due to a mental or physical disability also qualifies. All immediate family dependants must be completely financially dependent on the principal member and stay with them.

Up to what age can a child remain a child dependant on his / her parent’s medical scheme?

As soon as a child dependant turns 21, he / she will be seen as an adult dependent and the monthly premium will increase from the following month. If the child dependant is completely financially dependent on his / her parents, they can remain on their medical scheme as adult dependents. If not, they will have to join their own medical scheme. If a child dependant is a full time student, they can remain on their parents medical scheme as child dependants, up to a specific age (24, 26 or 27), depending on the scheme they are members of and the scheme rules. Proof of full time studentship will have to be provided to the scheme each year and UNISA does not count (not accepted).

When does a dependant need to join their own medical scheme?

According to the Medical Schemes Act, if you are an adult dependant on a medical scheme (excluding spouse / partner) and you are no longer fully financially dependent on the main member (meaning that you earn a monthly income greater than the state grant), you need to join your own medical scheme.

Does the total monthly premium increase and if yes, when?

Yes, the total monthly premium increases every year on the 1st January.

When can I change (upgrade only) my benefit option within my current scheme?

You have the opportunity once a year to change / select your benefit option within your current scheme for the following year. This period in which you need to inform your broker or the medical scheme directly of this option change is more or less from the 1st November to the 10th December. The new option will then come into effect on the 1st January of the following year.

Can I downgrade my medical scheme option within my scheme at any time of the year?

Yes you can, but you will have to provide the medical scheme with a valid reason as to why you would want / need to. The other very important thing to keep in mind is if you have an option with a savings component and you have depleted the savings or spent more than what was allocated to you on a monthly basis, the scheme will request that you pay the balance back to them.

When can I change medical schemes?

You can do this at any time of the year. You just need to keep the following in mind:

  • You need to give your current scheme notice – most schemes request a full calendar month.
  • If savings is depleted, you will need to pay some money back to your scheme.
  • The new scheme can implement underwriting.

What are Prescribed Minimum Benefits (PMB)?

Prescribed Minimum Benefits (PMB) is a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. There are 271 PMB conditions listed in the Medical Schemes Act, which includes the 26 PMB chronic conditions which has to be covered by all medical schemes. According to the Act, all medical schemes have to pay for the diagnoses, treatment and care of PMB conditions at cost. This treatment can be rendered by State Hospitals or a Designated Service Provider (DSP) according to clinical protocols, criteria and scheme rules.

What is a Designated Service Provider (DSP)?

This is a healthcare provider (GP, Specialist etc.) or a group of providers (Hospitals) selected by the medical scheme as the preferred provider / providers, to provide to all its members the diagnosis, treatment and care in respect of one or more Prescribed Minimum Benefit (PMB) conditions.

I found out I am pregnant but I don’t have a medical aid. Will I be covered if I join?

Unfortunately not, because pregnancy qualifies as a pre-existing condition and a medical scheme will implement a 12 month condition-specific waiting period on pregnancy.

Will my baby be covered when born?

Yes, your baby will be covered immediately once born. You have to however register the baby on your medical scheme, within 30 days from date of birth.

What is a chronic medication formulary?

This is the list of specific chronic medication each scheme covers for the treatment of chronic conditions covered on your option. Please note that this will be generic medication, because medical schemes in general do not cover original chronic medication.

What happens if my medication is not on the formulary?

There is one of three things that can happen:

  • You will have to change to a medication which is on the formulary.
  • You will have a co-payment on your current medication.
  • Your doctor will have to send the scheme a motivation to why you HAVE to be on that specific medication.
  • There is no guarantee that the scheme will approve the medication once the motivation has been received.

What does it mean if the scheme says they pay up to the MPL rate for medication?

MPL stands for Medicine Price List. This means that each chronic medication has a specific price and that price is calculated according to the Medicine Price List. The scheme will only pay up to that specific Rand amount. Any cost difference over and above that amount will be for the members own account.

What does Annual Threshold mean and how does it work?

The Annual Threshold is a Rand limit you need to reach for day-to-day expenses, before the scheme starts paying for day-to-day expenses from their side again. To reach that level, all day-to-day claims are paid from your available savings until depleted. Certain claims paid from available savings do accumulate (at normal medical scheme tariff / rate – 100%) towards the Annual Threshold. Once savings is depleted you pay for day-to-day expenses from your own pocket and submit them to your medical scheme. That is called the Self-payment Gap. Those claims all accumulate at the normal medical scheme tariff / rate (100%) until you reach the Annual Threshold amount on your option. The medical scheme will now pay for day-to-day benefits at the normal medical scheme tariff / rate and up to benefit limits.

Example: Your annual available savings is R8 000 and your Annual Threshold to reach is R12 000. This means that your Self-payment Gap is R4 000 (R12 000 – R8 000). Once your R8 000 has been depleted, you will have to pay for day-to-day expenses (Self-payment Gap) until you have reached the Annual Threshold of R12 000. Now this looks and sounds like you only need to spend R4 000, but that is not the case. The reason for saying this is because claims accumulate at the normal medical scheme tariff / rate. This means that should you see your GP and he charges you R350 for the consultation, only the normal consultation fee (100% of scheme tariff / rate) which is around R192 will accumulate. This means that you will have to spend much more than just R4 000 to reach the Annual Threshold.

The other “catch” is that if you have a benefit limit of R3 000 for dentistry before and after Threshold, it will work as follows: If you visit the dentist while you have available savings and the cost is R800, the full amount will be paid from your available savings, BUT it will also be deducted from the benefit limit once Annual Threshold has been reached. This means that if you reach your Annual Threshold and the scheme must start paying for day-to-day expenses and you go to the dentist, you will only have a benefit of R2 200 (R3 000 – R800) available and NOT the R3 000.

How long do I have to submit a claim before it becomes stale?

You have to submit your claim to your medical scheme within 4 month’s from date of service.

What is the difference between Medical Insurance and a Hospital Plan / Medical Aid?

Medical Insurance products (OnePlan, Clientele, AIG, Affinity Health etc.) are not registered as South African medical schemes and is regulated under the Short-term Insurance Act. If you are on such a product and you now want to join a medical scheme, the scheme will not take that membership into account as previous medical scheme membership and full underwriting will be applicable.

Here are two main differences between Medical Insurance and a Hospital Plan / Medical Aid:

Medical Insurance pays a Rand value per day in Hospital – Medical Aid pays unlimited or up to an overall annual limit (R1m).
Medical Insurance does not cover PMB’s – medical Aid’s do.

Can I belong to a Medical Aid and still have Medical Insurance?

Yes, you can as Medical Insurance may be used in conjunction with your Medical Aid to cover any shortfalls you may accrue.