Becoming an adult can be a daunting task; especially when it comes to having to make your own financial decisions. One of these decisions that we have to face is taking out medical aid. We know we have spoken it about it before, but having a medical aid, or some kind of medical cover, is very important in South Africa.

With all the choices out there, we advise that you do your homework and compare various options before making a decision, which is why we have put together a quick guide to the medical aid lingo you need to know in order to help make your choice much easier.

Commonly used medical lingo:

  • Acute medication: this is medication that is prescribed to treat medical conditions that manifest quickly, such as bronchitis, tonsillitis etc, and only need a short bout of medicine before you get better.
  • Chronic illness: this is a medical condition that is ongoing and requires ongoing medical treatment. Examples include high cholesterol, asthma, diabetes etc.
  • Chronic benefits: this is medical aid cover that covers any chronic illnesses you may have. Each medical scheme has its own terms and conditions for this benefit so make sure you do the comparisons.
  • Chronic medication: this is the medication that a person suffering from a chronic condition will be prescribed. Different medical schemes will cover you for different medication; make sure that you are familiar with which medications are covered before filling your script. If the particular medicine you have been prescribed is not covered and therefore will not be paid for by your medical aid, find out if there is a generic you can take that is covered.
  • Claims paying ability: the amount of claims you can put into your medical aid differs per scheme and provider. Make sure you find this out before choosing a medical aid provider.
  • Co-payments: this refers to the percentage of the cost of a medical procedure that you are responsible for paying. Don’t forget that medical schemes only pay a certain amount for treatments so if your medical provider charges a higher fee, you are responsible to pay the balance.
  • Comprehensive cover: this is a medical scheme that provides both day-to-day benefits and hospital benefits.
  • Condition-specific waiting period: sometimes when a new member with pre-existing medical conditions joins a medical aid,,a waiting period may be required. This waiting period can range anything from 3 months to a year, depending on your circumstance. During this time, members may not claim for any costs linked with that specific condition.
  • Day-to-day benefits: these are your general medical costs for day-to-day care such as a GP visit, dentist, optometrist etc.
  • Dependant: any person who is covered by the medical aid plan’s principle member is referred to as a dependant. This can include children, spouse, life partners, siblings and parents of the principle member.
  • Deductible: this is a fixed cost that you will need to pay prior to certain medical procedures.
  • Designated service providers (DSP): medical aid providers generally have a list of healthcare providers that they would prefer you to use. Members will be able to obtain co-payment-free, unlimited diagnosis and treatment from these providers.
  • Elective surgery: these types of surgeries are any cosmetic procedures that do not have any medical purpose and aren’t associated with a life-threatening condition. They can include breast augmentation, tummy tuck, botox etc. It is important to note that your medical aid will not cover you for these types of surgeries.
  • Exclusions: these are medical conditions that, by law, medical aid providers don’t have to include in their scheme offerings. Conditions may include self-inflicted injuries, fertility treatments or cosmetic surgery.
  • Gap cover: this is essentially a top-up for your medical aid; it covers you for certain costs that your medical aid may not pay for, and in some cases, will cover you when your medical savings runs out.
  • ICD-10 codes: by law, every claim submitted to the medical aid needs to be accompanied by an ICD-10 code. The coding system was developed by the World Health Organisation in order to standardise the diagnostic process.
  • Late-joiner penalty: please refer to our previous blog “The meaning behind the “late joiner penalty” on your medical aid”
  • Medical savings account (MSA): this is where your own money is kept aside by your medical aid provider in order to pay for day-to-day medical expenses.
  • Medical scheme rate (MSR): this is the amount that your medical aid provider will pay to your healthcare provider.  For example if the MSR is 100% and your healthcare provider charges 100% of the MSR rates, the fee will be paid in full by your medical aid. If your healthcare provider charges 150% of the MSR rate, you will need to pay the difference.
  • Pre-authorisation: Before going into hospital, for any kind of treatment – life threatening or not – you are required to notify your medical aid and get authorisation from your scheme before you can be admitted.
  • Prescribed minimum benefits: these are medical conditions that, by law, have to be paid in full and without co-payments to all members of a medical aid. Conditions include HIV/AIDS treatments, certain cancer treatments and heart attacks.
  • Oncology: these are cancer treatments including, but not limited to, radiation, chemotherapy and laser treatment. Each medical aid plan offers different oncology cover.
  • Restrictions: these may include waiting periods, exclusions or late-joiner penalty depending on your risk profile.
  • Roll-over benefits: these are unused medical savings that a medical aid scheme carries over from the previous year, so that a member may take advantage of those benefits in the current year.
  • Tariff shortfall: this is the amount of money you will need to pay to your healthcare provider if they charge more than your medical scheme covers.