Don't be caught off-guard by your lack of medical aid benefits
Understanding out-of-pocket expenses, procedural co-payments, and pre-approvals
26 September 2024
JOHANNESBURG - In a perfect world, having medical cover would mean zero surprises when paying for healthcare. However, many South Africans are shocked when their medical aid benefits fall short, leaving them with unexpected out-of-pocket expenses – especially towards the end of a benefit year. Whether preparing for a routine check-up, planning surgery or facing an emergency, knowing the ins and outs of your medical aid cover is essential.
Out-of-pocket expenses
Even with comprehensive medical aid, you may find that not everything is covered. Out-of-pocket expenses are those costs that your medical aid doesn't cover, such as:
- Co-payments - when one must pay a portion of the total bill directly to the service provider. For example, if you need a specific procedure like a colonoscopy, your chosen medical aid benefit option might only cover a percentage of the costs, leaving you to cover the remaining via an upfront co-payment.
- Non-covered services - services or treatments that fall outside your plan's coverage. For instance, your plan may not include cosmetic procedures or specific alternative therapies.
- Out-of-network doctors or hospitals apply when going to a healthcare provider that is not on your specific plan's network list. You might be required to pay more or even cover the entire cost.
Medshield Medical Scheme offers various benefit options, and some offer 100% cover for network providers. If you choose doctors and hospitals within our preferred provider network, you'll likely avoid out-of-pocket expenses. However, you'll be liable for the cost difference if you go outside the network.
Procedural co-payments
A procedural co-payment is the amount you pay out of pocket before your medical aid covers certain healthcare services. Depending on your medical aid plan and the specific treatment or procedure, it can differ significantly.
For example, if your medical aid plan has a R5 000 procedural co-payment and you undergo a procedure that costs R20 000, you must pay the first R5 000 upfront to the service provider before your medical aid covers the R15 000). It is best to always review your benefit guide for your specific plan or contact your medical scheme before the procedure to ensure you understand the requirements.
Medshield's benefit options vary, with some offering higher levels of cover for in-hospital procedures, meaning lower out-of-pocket expenses after the procedural co-payment is met. Understanding your specific plan's procedural co-payments is crucial in managing your healthcare budget, particularly for planned procedures or elective surgeries.
Pre-authorisation and pre-approval
One of the most common pitfalls medical scheme members encounter is failing to get pre-authorisation or pre-approval for specific treatments or procedures. Without this, your medical aid may not cover the procedure, leaving you responsible for the entire cost.
Pre-authorisation is required for planned hospital admissions, surgeries, and other high-cost treatments. It involves contacting your medical aid to confirm that it will be covered before treatment or, in case of an emergency, as soon after the event as possible. Failing to get pre-authorisation can result in significant out-of-pocket expenses. For instance, with Medshield, if you require a planned hospital stay for surgery, you must contact our authorisation department at least 72 hours before the procedure. This process ensures that the treatment is medically necessary and falls within the parameters of your plan. Without pre-authorisation, you could face a hefty bill.
Pre-approval is more commonly required for expensive chronic medications or specialised treatments. It's a way for your medical aid to ensure that the prescribed treatment is appropriate and aligns with your plan's medicine formulary.
Emergency care versus urgent care
When every second counts in an emergency, it is critical that one understands what your medical aid will cover and what not. But what exactly qualifies as an emergency, and how does it differ from urgent care?
Emergency care refers to life-threatening situations requiring immediate treatment. South African medical schemes are required by law to cover Prescribed Minimum Benefits (PMBs) in emergencies at the nearest hospital, regardless of your plan. In true emergencies, such as heart attacks, strokes, or severe injuries, treatment will be covered, even if it's out of network. Medshield includes emergency cover as part of each benefit option, ensuring necessary care without worrying about the cost. However, it's important to note that emergency cover only applies when the situation qualifies as an emergency, and non-life-threatening conditions treated as emergencies may result in additional out-of-pocket expenses.
Urgent care covers conditions requiring quick attention but not life-threatening, such as minor fractures, infections, or severe flu symptoms. Medshield's coverage depends on the benefit option, and some plans may offer coverage for urgent care visits, but this may be subject to co-payments or consultation limits.
Quick tips to help avoid unexpected bills
- Submit claims promptly: Ensure your healthcare provider submits the claim to your medical aid within the required timeframe. With Medshield, claims are typically processed quickly, but delays in submission can lead to payment issues.
- Understand your statement: Your medical aid will provide a detailed statement outlining what has been covered and what, if any, amount you owe. Check this carefully to understand why certain expenses were or were not covered.
- Follow up on rejected claims: If your claim is denied, follow up with your medical aid to find out why. Often, rejections are due to missing information, incorrect codes, or failure to obtain pre-authorisation.
While choosing the right plan for your lifestyle and healthcare requirements is vital, knowing your plan's terms can save you time, stress, and money. Always read the rules, ask questions, and stay informed to avoid unexpected costs when using your cover. By taking control today, you can ensure peace of mind for the future.
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