How to Understand Your Health Plan

    January 11, 2017

    Being able to understand your health plan is vital if you want to get the best value for money. Not understanding the terms properly can lead to you having to pay expensive bills yourself.

    In this article, we will help you to understand the questions you need to ask because we’re looking out for you.

    Do you understand your health plan?

    Do They Limit Cover to Prescribed Medical Rates?

    The answer to this question is bound to be, “Yes”. Each insurance company determines prescribed medical rates.

    They look at the average costs for claims paid out in the preceding year. They weigh that up against the forecasted income for the next year. This enables them to determine what they will pay out for a procedure.

    understand your health plan

    How Much is the Cover?

    It is a common misconception that the medical aid will settle the full bill when you are in the hospital. Again, they will link the cover to the prescribed medical rates. In some instances, they may double or triple this cover.


    They could still catch you out if the doctor charges more than what the medical aid will pay. And they often will.

    Do Some People Prefer Certain Providers?

    In some instances, others expect you to use preferred service providers. If you do so, you will normally not need to pay anything in. This is because the medical aid has negotiated special rates with these providers.

    If you decide to go outside of the network, you might have to pay a co-payment. This would be in addition to the difference in fees between the prescribed medical benefits and what they would charge.

    Are There Prescribed Medications?

    This typically applies when you are on a plan that has unlimited coverage as long as you get your medication within the network.

    The medical aid will often give a prescribed list of medications that it will pay for. These will often be generics, and the list may exclude non-essential meds.

    Should you wish to buy medications that are not on the list, you will often have to pay for them yourself.

    When Does One Require Pre-Authorization?

    This is important to find out. It does not automatically follow that if a procedure is done in the hospital, your medical aid will pay for it. And they can therefore legally reject claims for non-essential procedures if they did not obtain proper authorization beforehand.

    What Annual Limits are There?

    Most medical aids will impose some sorts of limits regarding overall coverage. It helps them to limit their liability. It may also help to curb frivolous claims.

    Check what your annual limits are for GP visit, dentistry, etc.

    Is Your Condition Chronic?

    There are some conditions that the medical aid is obliged to treat. Should your condition be chronic, you should apply for your medical scheme to place you under chronic benefit.

    This will usually require your doctor to complete and sign a form. Also, the benefit is that you will no longer need to cover the cost of the medication from your medical savings account.

    The best advice when it comes to having you understand your health plan is to read the policy document. Check what the medical scheme does and does not cover. Ask questions about anything you are not sure of.


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    All info was correct at time of publishing