Frequently Asked Questions
Basics of Medical Aid
What is medical aid?
Medical aid is a form of insurance where you pay a monthly amount – called a contribution or premium – in return for financial cover for medical treatment you may need, as well as any related medical expenses. This means that if you fall ill suddenly, are involved in an accident or need emergency treatment, your health needs will be taken care of.
In South Africa, medical aids are governed by the Medical Schemes Act, which regulates the industry in a fair and transparent way.
How does medical aid work?
Medical aid schemes are actually non-profit organisations, where resources are pooled by a large number contributing individuals who can then access this money when they need to pay for various medical expenses. In a medical aid scheme, members pay a monthly amount called a premium or contribution into a “collective pot” that is administered by the scheme. This money is then used to pay out medical claims made by members.
How do medical schemes work?
Medical schemes are legal bodies registered in terms of the Medical Schemes Act for the purpose of defraying medical expenses of its members. As such, its sole purpose is to pay claims, not to make profits. In terms of the legislation medical schemes have to be financially sustainable and hold reserves in order to meet unexpectedly high claims, but all of those profits remain in the scheme as the property of the members. No dividends are paid to shareholders. Medical schemes are run by a board of trustees, at least half of which have to be elected by the scheme’s members. This board is responsible for managing the scheme in the interests of all its members.
What are medical aid waiting periods?
When you join a medical aid scheme, you’ll usually be subjected to a waiting period, which is a period of time during which you won’t be covered if you need to make a medical claim. Medical aid waiting periods form part of South Africa’s Medical Schemes Act and are imposed to protect medical aid schemes. If these waiting periods weren’t in place, people might only be motivated to sign up for a medical scheme when they found out they were unwell, which would make it very hard to keep schemes financially viable.
Can a medical aid refuse membership?
No open South African medical aid fund can legally refuse you medical aid membership. Closed medical aid funds on the other hand, which only exist for employees of certain companies for example, are not available to other members of the public and so you will be excluded if you’re not an employee.
It’s important to know however, that medical aid schemes do have the right to charge late joiner penalties or enforce certain waiting periods on new members, which can be up to 12 months for certain pre-existing conditions such as hypertension, asthma or pregnancy. This means that your new medical aid scheme will not pay out any claims that you incur within a certain time period that directly relate to these pre-existing conditions.
What is a late joiner penalty?
Late joiner penalties can be applied by medical aid schemes if you join after the age of 35, or if you haven’t belonged to a medical aid scheme for a specific period of time. Fees applied vary depending on the particular medical aid scheme concerned, but are calculated as a percentage of your monthly contribution.
What are prescribed minimum benefits? (PMBs)
Prescribed Minimum Benefits (PMBs) are a set of predefined conditions that form part of South Africa’s Medical Schemes Act. With PMBs, anyone who is part of a medical scheme, no matter what medical aid plan they’re on, can receive treatment for 270 hospital-based and 25 chronic conditions, and the price of these will be covered in full. The aim of PMB cover is to ensure that the wellbeing and health of South African medical aid members is safeguarded, and that private healthcare is more affordable. PMBs also cover any kind of emergency treatment and include certain out-of-hospital treatments.
Which medical aid is cheapest?
If you’re looking for the cheapest medical aid, your best option is to join a hospital plan, rather than try and make your budget stretch to a comprehensive medical aid option.
Types of Coverage
What do hospital plans cover?
Hospital plans mainly cover the treatment costs if you’re admitted to hospital such as ward costs, theatre fees, and accounts from other in-hospital providers such as anaesthetists or radiologists. Hospital plans also typically cover emergency medical expenses, whether you are admitted to hospital or not. To qualify as an emergency, the condition or event must be unexpected and need immediate treatment, for example treatment in the casualty ward of a hospital, trauma counselling or emergency medical services.
What are hospital cash plans vs. hospital plans?
A hospital cash back plan is a type of insurance where you’re paid out a daily cash amount (usually in a lump sum) should you spend time in hospital. In contrast, a hospital plan as part of a medical aid scheme covers the costs of in-hospital or emergency treatment you may need. Whether your hospital fees will be covered in full, or whether you’ll need to make a co-payment as part of your hospital plan, will depend on the specific provider you’re with and the plan you’re on.
What is medical insurance?
Medical insurance is a type of insurance where you’re paid a cash amount for each day you’re in hospital. However, you have to have been in hospital for at least three days in order to claim – so if you’re only in hospital for a day procedure, for example, you won’t be eligible for a payout. In addition, the daily allowance you’re paid out is designed to help with everyday expenses and won’t be enough to cover the whole cost of your hospital stay.
What's the difference between medical insurance and medical aid?
Medical insurance is designed to pay you out for daily expenses while you’re in hospital. You need to be in hospital for at least three days, and your daily amount won’t cover your entire medical bill.
Medical aid, on the other hand, is designed to cover all costs involved with being admitted to hospital, including the anaesthetist, any specialists you use, and take home medication. Depending on the plan you choose, your cover for your hospital stay can be unlimited.
What's the difference between hospital plans and medical aids?
A hospital plan covers you for any medical procedures that are performed in a private hospital, such as if you’re in an accident and need an emergency operation. If you need cover for medical attention given outside of a hospital, like seeing your GP, visiting the dentist or getting new glasses at the optometrist, a hospital plan would not cover these costs – however a medical aid plan would.
What is medical aid gap cover?
Medical aid gap cover is an additional insurance policy that you can take out over and above your medical aid plan. With this insurance, you pay a monthly fee and in return the gap cover provider pays you out a portion of the difference between what your medical bill is and what your medical aid pays for. In many cases with private hospitals, you may be charged more than what a medical scheme will cover – especially if you use a healthcare provider that is out of your medical scheme’s network.
COVID-19 Related
Coronavirus FAQ's
COVID-19 FACTS FEDHEALTH WANTS YOU TO KNOW
- Key facts
- There is an outbreak of a novel coronavirus (termed “2019-nCoV”) which originated in China.
Will Fedhealth be funding the COVID-19 vaccinations?
Is Fedhealth taking part in discussions to assist in securing and funding coronavirus vaccines in the country?
South Africa is participating in the WHO COVAX agreement, which aims to ensure that developing countries secure equal or at least simultaneous access to COVID-19
When should you call your GP?
Currently, the NICD lab is the only one testing for Coronavirus. If you, or a loved one, meet the following criteria, please call your GP (don’t visit their rooms in case you might risk infecting others):
What should I do if I suspect that I have contracted COVID-19?
Please remember that unless you’ve been travelling, or have had contact with people with known infection, your risk for contracting COVID-19 is almost negligible.
However, if you suspect that you might have contracted the virus and are showing signs of respiratory illness, please do the following:
Preparing for the upcoming flu season in the time of COVID-19
Getting an annual flu vaccination is your best defence against the flu virus, and goes a long way towards reducing hospital admissions and even deaths.
Telemedicine keeps you safe
Many GPs and specialists have made themselves available for telephonic consultations to assist patients without physically meeting them. These consultations can be claimed for from your benefits using the code 0130 – telephonic consultation (face-to-face contact needs to be avoided in order to use this code).
Postponing or cancelling elective surgery
Fedhealth urges that members reconsider undergoing any elective (non-emergency) surgery or procedures at this time, and delay it until the worst of the coronavirus is over.
Other member services that are useful during lockdown
On midnight on Thursday 26 March 2020, South Africa was placed under a national lockdown. This was part of the measures put in place by government to curb the spread of coronavirus in the country and limit fatalities.
Operating hours and service during lockdown
Operating hours of Fedhealth Customer Contact Centre and other services during the lockdown:
How will Fedhealth cover coronavirus tests and treatment?
How will Fedhealth cover coronavirus tests and treatment?
All beneficiaries on all plans will be covered for the testing and the management of COVID-19 once a positive diagnosis is confirmed. If you or one of your dependants tests positive for COVID-19, the benefit cover applies according to the Scheme Rules:
Membership and Benefits
Why should I have a medical aid plan?
If you don’t want to rely on South Africa’s public health system, getting medical treatment from a private provider can be hugely expensive. Receiving care in a private hospital if you’re ill or in an accident can end up costing thousands or even hundreds of thousands of Rands. Medical aid protects you from having to pay large unexpected sums of money out of your own pocket should you need medical help. It also means you can get treatment quickly, without needing to wait until you have the money available.
How do I choose a medical aid?
When it comes to choosing a medical aid, there’s no one-size-fits-all answer. The best medical aid scheme – and medical aid plan – for you depends on your specific circumstances such as your health, budget, age and family situation.
Which medical aid is best?
Trying to choose the best medical aid for you is a tricky task, as you can’t predict what the future holds. Also, every family is different, with different budgets and different health needs. Don’t be swayed by fancy advertising or how many other people belong to a certain medical aid – what matters is that you’ve considered all of the below factors before deciding which medical aid is “best” for you…
Can I add my spouse as a beneficiary on my medical aid?
Yes, you can. Within the medical aid industry, a beneficiary on your medical aid is known as a “dependant”. According to South Africa’s Medical Scheme Act, medical aid dependants can include the spouse or partner of the main member, as well as their biological children or father and mother – if they are financially dependent on the main member. Your boyfriend or girlfriend is also considered to be your spouse, provided they are living with you permanently.
For most medical aids in South Africa, the premium for a dependant is less than for the main member, so it makes sense to combine medical aid costs among one family. This is good to remember when choosing your medical aid plan, many of which are geared specifically towards families.
Can I add my baby as a beneficiary on my medical aid?
Yes – as soon as your baby is born, he or she is eligible to be added as your dependant to your medical aid, and they’ll be covered immediately. With most medical schemes, you’ll need to provide a birth certificate in order for them to be added. To ensure your baby is covered without any waiting periods, medical schemes can request that the baby is added within 30 days of the baby’s birth. If you add your baby after this time period your child may be subject to waiting periods which can be 3 months general waiting period or 12 months if your baby was born with a specific condition.
Can I add my parents as beneficiaries on my medical aid?
Most medical aids in South Africa allow you to add your parents to your medical aid plan as dependants, as long as you can prove that they are financially dependent on you. The same applies to adding people like your nieces and nephews if they have been orphaned, for example, or your siblings or grandparents.
Adding your parents onto your medical aid will result in cost savings, as they’ll be covered at lower rates for dependants. In many cases, if you are adding an adult dependant, there’s a general waiting period of around three months – and up to twelve months if that adult dependant has a pre-existing condition. Once this waiting period is over, these dependants will then have the same level of cover as the main member, with access to the same risk benefits.
Can I add my boyfriend or girlfriend as a beneficiary on my medical aid?
Yes. If your boyfriend or girlfriend is living with you, you will be able to add them as an adult dependant to your medical aid – just as you would if they were your spouse. Adding your boyfriend or girlfriend onto your medical aid will mean costs savings, because they’ll receive the same cover as you (as the main member) but at lower dependant rates.
Be aware that if you’re adding your boyfriend or girlfriend as an adult dependant, there’s usually a waiting period of about three months before they’re covered, and even longer if they have a pre-existing condition.
Can I get medical aid if I’m already pregnant?
Yes, you can take out medical aid (as an individual medical aid member) if you’re already pregnant, although any costs associated with your antenatal care and the birth of your baby will not be covered by your new medical aid .
Claims and Processes
How do medical aid savings work?
With medical aid savings, part of your contribution is paid into a savings account and is not pooled with other members’ contributions. The money in this savings account is your money and is to be used for your day-to-day expenses such as prescribed medication. The total annual amount in a savings account is made available in advance for that year. In accordance with South Africa’s Medical Aid Act, your savings portion will not exceed 25% of the annual contributions that you pay. Once your savings are used up, you’re responsible for any other medical expenses. If you have any savings left over in a certain year, these are carried over to the following year.
How do I submit a claim to medical aid?
Submitting a claim to medical aid is easy, as long as you have all your paperwork in order. In general, you’ll need to collate all itemised bills and invoices that relate to the health procedure you’re claiming for. This could mean invoices from hospitals, anaesthetists, general practitioners, specialists, or invoices for medication you’ve bought from a pharmacy.
Every medical aid has a different claims procedure, but generally you’ll need to submit your personal details, your medical aid number, and then the relevant documentation as outlined above. You can normally do this via email, fax or post.
What do I need to apply for medical aid?
When you apply for a medical aid plan, you’ll need to submit several sets of personal details for yourself and your dependants. This application process helps your medical aid decide whether you meet their joining criteria and can become a member.
For most medical aid schemes including Fedhealth, you’ll need to submit the following details:
- Personal details – including your name, ID, date of birth, language, marital status and contact details.
What are medical aid rates?
Medical aid rates are the rates at which medical schemes in South Africa will cover a treatment or procedure provided by a specialist in a hospital.
In South Africa, The Reference Price List (or RPL) is a set of guidelines published by the Department of Health which outlines the recommended charges for procedures performed in hospital by specialists and anaesthetists. However, health providers like doctors and specialists are not bound by these guidelines, meaning that they can charge what they would like for a procedure (sometimes as much as five times more), as long as they are considered to be of fair value by the patient.
Specific Medical Aid Terms
What is a co-payment?
Depending on the plan you’re on or the healthcare provider you use, your medical aid plan may not cover your entire medical expense. In this case, you may be responsible for a co-payment, which is the amount that you must pay from your own pocket for a particular treatment or procedure as determined by your medical aid scheme.
How much this co-payment is depends on your specific circumstances: whether it’s for an in-hospital procedure, or for medication, and then which hospital and specialist you’re using. If you use network providers only, you probably won’t have any co-payments;
What is a closed medical aid scheme?
A closed medical aid scheme, also called a restricted medical scheme, is a medical aid scheme that is only open to certain groups of individuals rather than to the general public. These groups of people could include employees from a company, or members of a particular industry. The scheme is then not allowed to exclude anyone within that group.
Closed medical schemes are required to follow the same rules as open schemes, which are governed by the Medical Schemes Act of 1998.
