Hospital Cover Terminology Explained

    Understanding the hospital cover terminology used on medical plan sites is essential to making informed decisions.

    It will help you to understand better the meaning of the words used when browsing for medical cover options.

    Chronic Disease List (CDL) – Hospital Cover Terminology

    It is a list of chronic diseases that form part of the Prescribed Minimum Benefits (PMB).

    PMBs apply to fees charged in State hospitals and should be offered by all medical aid schemes in South Africa.

    Hospital Cover TerminologyIt includes about 25 chronic diseases and more than 270 emergency conditions.

    Also, the list is on the Council for Medical Schemes site.

    Day to Day Benefits (DDBs) – Hospital Cover Terminology

    These are the out of hospital benefits by the medical scheme and includes:

    • Investigative radiology
    • Optical services
    • GP costs
    • Specialists fees
    • Pathologist services
    • Prescribed medications
    • Specified self-medication

     

     

    Designated Service Provider (DSP)

    It’s a service provider that renders health care to medical scheme members according to the agreed tariff structure.

    Also, the medical scheme must appoint the DSP.

    In other words, if an unapproved DSP offers cheaper hospital tariffs than those listed in the medical scheme’s network, the policyholder will not be covered.

    Medical Scheme Tariff (MST)

    That is the tariff a medical scheme will pay for specific in and out of hospital treatments offered by an approved DSP.

    Emergency

    There are many emergency situations as defined in the South African Medical Schemes Act No. 31 of 1998.

    So it stipulates that specific minimum conditions and treatments including, emergency care, must be covered by medical schemes.

    So an emergency is a sudden situation in which one needs immediate care, surgery or hospitalisation:

    • Life threatening
    • Long-term suffering
    • Serious health conditions
    • Disability
    • Also, lasting damage to organs or limbs.

     

    Elective Surgery (ES)

    Most of the more affordable medical aid options do not include any form of elective surgery.

    If not covered, the policyholder will have to motivate reasons for ES and, if granted, will be subject to pre-authorisation as well as specific limits.

    Also, ES is surgery to correct a non-life-threatening condition including cosmetic operations.

    Dental Information Systems (DENIS)

    DENIS is a pre-approved service provider contracted by the medical scheme to provide dental procedures.

    Limits

    Limits are the maximum annual out-of-hospital benefits payable to a member and dependants.

    With most of the cheaper schemes, Limits for out-of-hospital care are low.

    However, in-hospital care Limits are fully covered.

    So reviewing the Limits imposed by their medical schemes is critical.

    If for example, a medical scheme Limits cover for visits to GP’s at 70%, the member must be aware that he/she will be responsible for the outstanding 30% amount, known as a co-payment.

     

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