ABC's of medical schemes

Do you understand the medical scheme dialogue?

What is the difference?
Understanding medical scheme dialogue

In laymen’s terms, the purpose of a medical scheme is to ensure that you are able to pay for treatment received from either a General Practitioner (GP) or any other service provider while in or out of hospital.

It is therefore important to ‘insure’ your health. "Accidents, illnesses and your family’s health is unpredictable. If you cannot afford the best level of cover, then you need to take at least what is affordable for you. The bottom line is that you need some kind of medical scheme product." says Rudolph Ackermann, CEO Manage All.

We are bombarded with a number of medical schemes as well as different health insurance plans. It is indeed a difficult task for any person to choose the correct medical cover needed. 

Selecting the most appropriate medical scheme cover in South Africa, is complicated for the layman as there is such a wide selection to choose from – each having strengths and weaknesses!

Most medical schemes are classified into six levels of cover namely: Low Income Medical Scheme (LIMS), Hospital Plans (not hospital insurance) Basic, Standard, Executive and Ultimate options. With the above in mind, one might begin to ask – what is the correct medical scheme and option/plan for me? What do I get from each level of cover? Are these levels of cover sufficient for any person, – irrespective of age, medical conditions, family size or any other needs? What can I expect the medical scheme to pay for?

Your needs for medical scheme benefits can change every year and therefore you need to evaluate your medical scheme benefits annually, thus ensuring that your benefits keep up with your needs. 

Medical schemes will upgrade your benefits to a better/higher option or down grade to a lower option with less benefits, only once a year, in November/December for implementation on 1 January of each new year.

LIMS options are usually the Capitation or Network options offered by medical schemes, where you need to make use of specific hospitals and contracted doctors with limited benefits for medicine, dentistry and optical benefits. These options are income based and designed for low income earners who need basic private healthcare. These options are therefore not ideal for anyone who wants ‘freedom of choice’ with regard to their choice of health care providers and who needs more comprehensive cover.


Hospital plans offered by medical schemes, is exactly what the name indicates – a plan covering only those benefits while hospitalised. It will cover all the general hospital benefits such as accidents, heart attacks and any other procedures or services which need to be performed in a hospital. 

Hospital plans offered by a medical scheme will not cover any ‘out-of-hospital’ benefits such as consultations, acute medication, dentistry and optical. It is designed for young and healthy people, under the age of 35, and not exceeding two people per family. Hospital plans are not designed to cover older people and families with children due to the benefit limitation. 

In general, these options offer limited cover on procedures such as back and neck operations, joint replacements and prosthesis. Often the medical schemes can levy a co-payment on these options, for such procedures. However this can be an extensive amount, and normally not budgeted for.


Basic options

These options are designed to cover basic needs. The basic options are comprehensive, offering in-hospital and out-of-hospital benefits. It is again designed for young and healthy people, with low medical expenditure, such as consultations, medication or dentistry. The family should be small and with limited needs to consult with a healthcare provider. The benefits available will cover all types of benefits but the value of each benefit will be less than those options with a higher premium.


Standard options 

These are options on which most people should be with a healthy family and little or no chronic conditions. These options are designed for people who are healthy, and take care of their health by having a general check-up every year and visit a dentist, at least once a year. 

It is suitable for a moderate family with healthy habits. This level of cover will cover 27 Prescribed Minimum Benefits (PMB)/chronic diseases, known as the Chronic Disease List (CDL) such as hypertension, cholesterol, asthma, strokes and epilepsy.


Executive options 

Theses options are designed for the person who needs extensive cover. It covers up to 62 chronic conditions which includes the 27 PMB or CDL conditions. The larger family will opt for this level of cover. It is usually the family with two of more children and the adults are above the age of 45 years, using moderate chronic medication and visit a healthcare provider on a regular basis. 

These options offer ‘peace-of-mind’ for the family and most health needs will be satisfied. Limits on out-of-hospital may exist on certain benefits such as medicine and optometry, however extensive benefits on consultations and in-hospital benefits.


Ultimate options 

These are the flagships of medical schemes and offer the best benefits on all levels of cover. Ultimate options are rich in benefits and generous limits may apply. 

It is designed for the person who does not want to manage his medical scheme but rather pay a high premium to cover most of his needs. It is usually the person with no children, extensive chronic medicine usage and persons in a higher income bracket. These options normally pay up to 300% of the medical scheme tariff, with little or no co-payments for procedures or services such as MRI and CT scans.

You should compare different medical schemes and the different benefit options medical schemes offer, keeping in mind you and your family’s needs. It is not an easy task and you would have to ask some pertinent questions like “Will you allow your GP to treat your cancer or would you prefer to see a specialist? Do you want to cover the day to day medical expenses yourself and just keep the option to cover the in-hospital expenditure by a medical scheme?

It is not an easy task, and can be quite overwhelming at the best of times, once you have assessed you and your family’s medical needs, you could then call in the services of a specialist medical scheme consultant so that each option and benefit can be explained and in so doing come up with a comprehensive plan that will not leave you or your family in the lurch when you need it most and you do not have to worry about insurmountable medical expenses and focus on getting better.


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