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. There are 26 different open medical schemes in South Africa and the cover you get will depend on the provider you choose and the type of medical aid plan you’re on.
Your cover will always include a minimum set of benefits (such as in-hospital treatment and treatment of chronic conditions) but if you’re on a more comprehensive medical aid plan, you can also be covered you for medical expenses such as GP visits, dental treatment and prescribed medication.
So how do you pick the right medical aid plan for your needs? Here are a few things to take note of:
Think about your needs and budget
Are you young, single and healthy? Are you married with small children? Your life stage and needs will influence which medical aid plan you should be on, as well as how much you can actually afford to pay each month.
Compare all your options
There are so many different medical aids to choose from, so you need to ensure that you’re comparing the same benefits alongside each other, and not simply choosing the cheapest option available to you.
Note any waiting periods
You should know that some medical aids impose waiting periods when you join – and these can be anywhere from three months general waiting period for all medical expenses to a secondary period where you’re not covered for any pre-existing condition for up to 12 months. So check these before you sign up.
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.
The concept of a medical scheme is based on the insurance principle whereby risk is spread (a risk pool) amongst a large number of participants, the members and their dependants (collectively beneficiaries).
From a member's perspective, belonging to a medical scheme means that the payment of monthly premiums (contributions) ensures healthcare costs incurred by beneficiaries are paid based on a pre-determined benefit structure.
When you join a medical aid scheme, you have a range of choices for the benefits you’ll receive, such as what kind of doctors and specialists are covered, what procedures are covered, and how much you’re covered for day-to-day medical expenses.
Depending on the level of benefits you choose, you’ll pay a different contribution amount each month. Because schemes belong to the members, any extra funds stay in the scheme and are used for the benefit of scheme members.
There are two types of medical schemes in South Africa:
Open schemes are open to any South African citizen
Closed schemes are designed for specific groups of people only, such as employees in a company
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.
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.
What kinds of waiting periods are there?
There are two main types of waiting periods:
General waiting period: This is usually three months in length, depending on the medical aid scheme you join. During this time, you have to pay your normal monthly contributions, but you aren’t entitled to claim any benefits, except in certain instances with claims relating to PMB's
A secondary waiting period: This is usually around 12 months long and is related specifically to treatment for any pre-existing conditions you had when you joined the scheme.
What is the duty of medical aid schemes?
Medical aid schemes in South Africa have a legal duty to be financially sound and this can only be achieved by balancing the risk profile of members. This is because younger and healthier members generally contribute for a reasonable period before they make major claims, and during this time they are subsidising the higher claims of older and more sickly members. This is cyclical, so that when these young healthy members get older, their claims are then subsidised by the younger and healthier members once again.
If people made large claims shortly after joining a scheme, and then cancelled their membership once they were well again, members would find they would have to pay much higher contributions, and the scheme may not be able to function financially at all.
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.
How does a doctor decide if my condition will be covered by a PMB?
Your doctor will look purely at your symptoms to decide whether you’re covered under a PMB. In other words, they won’t look at how the condition was contracted in the first place, but rather the symptoms you are displaying at that current point in time. They will then decide where you should receive the treatment in terms of in the doctor’s surgery or in hospital.
What kind of conditions does a PMB cover?
You can read the full list of hospital-based PMB conditions covered, which are grouped into 15 broad categories and include things like heart attacks, strokes and pneumonia. The 25 chronic diseases in the PMBs include conditions like epilepsy and bipolar mood disorder – read the full list.
Where can I get help with a PMB related issue?
The Council for Medical Schemes (CMS) was established to supervise medical schemes in South Africa and exists to protect your right as a consumer to be treated fairly. If you need help with a PMB issue, contact them for guidance.
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; if you use an out-of-network hospital or specialist, then you may pay a co-payment. Co-payments are either a percentage of the cost of your medical expense or a fixed amount
As part of the rules set out by the Council of Medical Schemes in South Africa, you’re not allowed to be charged a co-payment for a Prescribed Minimum Benefit (PMB), as long as you use the scheme’s Designated Service Providers (DSPs) or use medicine on the scheme’s medicine formulary. However, if you use a different provider other than the DSP, you may be liable to pay a co-payment as part of the scheme’s rules.
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 types of expenses does a hospital plan cover?
Usually, a hospital plan covers the following sets of costs to varying degrees:
The account for hospital costs, such as ward and theatre fees, supplies and medicine dispensed in hospital. In most cases, these hospital costs will be covered in full.
The accounts from doctors and specialists, such as a gastroenterologist if you’re having an appendectomy. These costs will usually be covered in full if they’re in your medical aid’s network of specialists.
Accounts from other providers, such as physiotherapists, x-ray departments. These are covered in different rates depending on your plan and provider.
With a hospital plan, you’re responsible for day-to-day expenses such as a visit to your doctor or buying prescribed medication you may need. Because hospital plans offer a basic level of cover, they’re the cheapest of all medical aid plans available. Also, for some treatments and procedures, you’ll need to pay an amount out of your own pocket, which is called a co-payment. These co-payments apply to the hospital bill and are usually paid upfront to the hospital.
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.
More about hospital cash back plans
Money from a hospital cash back plan is meant to compensate you for not being able to work and earn money while you’re in hospital, and the amount won’t cover the costs of your medical treatment. These plans usually only pay out from the fourth day you’re admitted to hospital, and you can use the money for anything you want, whether it is affording grocery bills or paying for school fees.
More about hospital plans
Hospital plans like those offered by Fedhealth are one of the most basic, and essential, forms of medical aid. Typically, these kinds of 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. Many people start out on a hospital plan when they are young, fit and single and don’t foresee many medical expenses. Then, as they get older and have more dependents, they move on to more comprehensive medical aid options.
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.
What can you claim for on your medical aid?
Depending on the medical aid plan you’re on, you can claim for in-hospital treatment, as well as other benefits like screenings for certain diseases, day-to-day expenses like medication or GP visits, and dental treatment. Medical aid schemes usually require that you use their own network of hospitals and healthcare providers to be fully covered: if you use providers outside of the network, you may be liable for extra charges.
Who regulates medical aid schemes?
The way medical aid schemes function is governed by South Africa’s Medical Schemes Act – this ensures that your rights as a member of a medical aid are protected, and that you get access to healthcare when you really need it.
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.
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.
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.
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.
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.
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 if I’m over a certain age and have never had medical aid?
As mentioned above, many medical aids do charge “late joiner” penalties if you are over a certain age and have never belonged to any medical aid fund, or have had gaps in your previous membership of any medical aid
What if I have no pre-existing conditions?
Even if you don’t have any pre-existing conditions, medical aid companies can impose a general waiting period of three months on you as a new medical aid member, before paying out any claims.
Why can’t I make a claim as soon as I join a medical aid scheme?
It’s important to remember that a medical scheme does not operate for profit. If all its members only joined medical aid schemes in order to immediately make claims, these schemes would not be able to stay solvent. They would struggle to pay out any of their existing members’ claims – even those who’d been contributing with no claims for years and years.
There are strict rules and regulations governing the industry and Fedhealth always abides by these regulations, which were stipulated in the Medical Schemes Act 131 of 1998. With an average of five days in paying out claims, find out more about what sets us apart.
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.
Because of this distinction, hospital plans are much cheaper than full medical aid plans, because you get less coverage. Here’s more on these two healthcare options:
A hospital plan requires you to pay a monthly premium that would then cover you for treatments and procedures as an in-patient in a private hospital. Any medication or doctor visits out of hospital would be for your own account. If you need to go into hospital for a planned procedure, you would need to get authorisation from your hospital plan provider beforehand, except in an emergency, when your provider would arrange your admission directly with the hospital.
Many medical aid plans provide both in-hospital and out-of-hospital cover, depending on which option you choose. So you’ll be covered for all the things a hospital plan covers you for, plus day-to-day medical care, such as going to the doctor and dentist. Depending on your plan though, your day-to-day savings (called your Medical Savings Account or MSA) are limited up to a certain point. So, make sure you do your research before signing up to a medical aid plan, to ensure the limits will be enough for you and your family.
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 .
The only exception in this case could be if you are employed by a company and they offer a group medical aid. The scheme may decide to cover your antenatal care and birth (if you sign up while pregnant), based on the claims experience of that company, and the associated risks.
Why won’t the birth be covered by my medical aid?
Many women (and their partners) only think about signing up for medical aid once they become pregnant – after all, having a baby can be expensive, and those medical bills soon add up. But if everyone did this, medical aid schemes would not have enough funds to pay out for all the procedures associated with pregnancy and birth at private hospitals (which can add up to hundreds of thousands of ). Schemes call this anti-selection, where you’re only taking out medical aid because you need it. It’s the same concept as only taking out car insurance once you have an accident and need someone else to pay for the repairs.
That’s why medical aids have certain waiting periods (of up to 12 months) that are associated with pre-existing conditions, like pregnancy. This means that for a certain time period (known as the waiting period), they will not pay out any costs associated with that specific existing condition. So, if you sign up for medical aid while you’re pregnant, your baby would be born during this waiting period and you wouldn’t be covered for expenses relating to your pregnancy or the birth. There is also another waiting period called a 3-month general waiting period during which time no expenses will be covered at all, except emergencies where the emergency is a Prescribed Minimum Benefit.
Is it still worth taking out medical aid?
Definitely. Because once your baby is born, they will require medical services at some point, and therefore they need to be signed up for medical aid. If they require urgent medical attention at any time after they are born, a scheme like Fedhealth will pay for it, regardless of the stipulated waiting period
Should I tell the medical aid company that I’m pregnant when I sign up?
It’s vital that you tell the medical aid company about any pre-existing condition you may have – for example that you’re pregnant – when you sign up. If you don’t tell them this and they subsequently find out, it’s very likely that your membership will be terminated, which could impact your own health, and the health of your baby.
There is an outbreak of a novel coronavirus (termed “2019-nCoV”) which originated in China.
The origin of the current strain is thought to be from animals.
The virus is contagious between people.
Symptoms can include a cold or organ failure in some severe cases.
Those with vulnerable immune systems are at higher risk.
On 31 December 2019, the World Health Organization (WHO) China country office reported a cluster of pneumonia cases in Wuhan City, Hubei Province of China. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been confirmed as the causative virus of Coronavirus disease 2019 (COVID-19). As at 3 April 2020, there was over one million cases reported globally and 50 000 deaths.
Here in South Africa
The first case of Coronavirus in South Africa was confirmed on Thursday 5 March 2020. The patient had returned from a trip to Italy and, together with his doctor and the doctor’s family, were placed under quarantine upon diagnosis. There are now over 1 400 confirmed cases and five deaths.
Signs and symptoms
Symptoms of 2019-nCoV may appear in as few as two days or as long as 14 days after exposure. Symptoms may include:
Shortness of breath
Severe respiratory illness
Multiple organ failure
People with underlying medical conditions may experience worse symptoms and even death.
The NICD encourages the public to continue practising hand hygiene and cough etiquette, and adhering to the following:
Wash your hands thoroughly for at least 20 seconds with soap and water especially after direct contact with ill people or their environment.
Consider getting a hand sanitizer (minimum alcohol content 70%) for when you’re out and about, or have to use biometric access systems. If your hands are dirty or soiled, rather wash with soap and water.
Don’t visit markets where live animals are sold.
Avoid touching your face, eyes, nose and mouth.
Avoid close contact with people who are sick, or suffering from acute respiratory infections.
Stay at least two metres away from those coughing or sneezing.
Stay home when you are sick.
Cover your mouth with a paper tissue or handkerchief or the inside of your elbow when coughing or sneezing. Dispose of tissues immediately and wash hands.
Clean and disinfect frequently touched objects and surfaces.
If possible, postpone any unnecessary international or local travel.
Avoid going to hospitals unnecessarily. Where possible, delay non-emergency/elective procedures.
Travellers with symptoms of acute respiratory infection should practice cough etiquette (maintain distance, cover coughs and sneezes with disposable tissues or clothing and wash hands).
Health practitioners should provide travellers with information to reduce the general risk of acute respiratory infections, via travel health clinics, travel agencies, conveyance operators and at points of entry. Travellers should self-report if they feel ill.
How is this family of viruses transmitted?
Respiratory droplets that are airborne
Shared objects such as clothes, utensils and furniture that carry infection
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 vaccines. S.A. does not qualify for subsidised access and the government, therefore, needed to make payment to secure access to COVID-19 vaccines via COVAX. In addition, the government is currently in negotiation to secure further vaccine supplies through bilateral deals with the relevant pharmaceutical companies. At this stage, Fedhealth specifically has not been approached by Government to participate in any talks or negotiations but the Health Funders Association (HFA) as an Industry body is representing their member schemes. Medical Aids will be an important funding mechanism for government as approximately 9 million people are covered by medical aid. By making the vaccine a Prescribed Minimum Benefit (PMB), Medical Aids will have to cover the costs of the vaccine for its members and thereby taking some of the financial burden away from government.
What are the options being considered by the company to fund and secure covid-19 vaccines in the country?
Since the primary role of a medical aid remains the funding of medical services and medication, the scheme will ensure that all members and beneficiaries are covered for the vaccine. Although it is difficult to make an accurate projection of the actual cost at this early stage due to various unknowns like the type of vaccine which the government will approve, the scheme is comfortable that it will be able to cover the cost of the COVID-19 vaccine in 2021 from risk for all its members without impacting its 2021 financial budget.
Will Fedhealth also consider putting aside funding for vaccines for non-members? And how will that work, will it be on a pro-rata basis?
A Medical Aid works on the same basis as a mutual fund and is a not-for-profit organisation. The funds, therefore, belong to the members who contribute every month through their contributions. The scheme will therefore not be able to utilise members’ money to fund vaccines for non-members without approval from members. Having said that, it must also be taken into account that other illnesses and diseases have not gone away due to COVID-19 and the scheme still needs to honour its “normal” obligations to its members. In fact, most members have delayed elective surgeries due to the pandemic and the scheme is expecting a significant increase in claims once members deem it safe again to go for these procedures. It is therefore unlikely that the scheme will be in a position to contribute to the funding of vaccines for non-members.
How many members more or less does the company have at the moment? And why is it important for the company to ensure that its members have access to vaccines?
Fedhealth currently covers 144 000 beneficiaries in total. Besides being the business of a medical scheme to look after the health of their members it is also important for medical schemes to manage costs and especially in-hospital costs which remain the largest cost driver. Therefore avoiding expensive in-hospital and ICU treatment by funding the vaccine is worth the cost of the vaccine.
Does Fedhealth believe/estimate that it could supply most of its member with vaccine access this year still? Or what is the estimated timeline?
South Africa is participating in the WHO COVAX agreement thus timelines would be dependent on this. Estimations for delivery of first vaccines to participants in the scheme is mid-2021. The scheme will then be subject to the roll-out plan recommended by the government. The hope is that all members will be able to get the vaccine before the end of 2021. From a scheme perspective, it will be important for us to be able to prioritise the higher risk members with co-morbidities.
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):
Criteria for Person Under Investigation (PUI)
Persons with acute respiratory illness with sudden onset of at least one of the following: cough, sore throat, shortness of breath or fever [38°C (measured) or history of fever (subjective)] irrespective of admission status.
In the 14 days prior to onset of symptoms, met at least one of the following epidemiological criteria:
Were in close contact1 with a confirmed2 or probable3 case of SARS-CoV-2 infection;
Had a history of travel to areas with presumed ongoing community transmission of SARS-CoV-2; i.e., Mainland China, South Korea, Singapore, Japan, Iran, Hong Kong, Italy, Vietnam and Taiwan
Worked in, or attended a healthcare facility where patients with SARS-CoV-2 infections were being treated
Admitted with severe pneumonia of unknown aetiology.
1 Close contact: A person having had face-to-face contact or was in a closed environment with a COVID-19 case; this includes, amongst others, all persons living in the same household as a COVID-19 case and, people working closely in the same environment as a case. A healthcare worker or other person providing direct care for a COVID-19 case, while not wearing recommended personal protective equipment or PPE (e.g., gowns, gloves, NIOSH-certified disposable N95 respirator, eye protection). A contact in an aircraft sitting within two seats (in any direction) of the COVID-19 case, travel companions or persons providing care, and crew members serving in the section of the aircraft where the index case was seated.
2 Confirmed case: A person with laboratory confirmation of SARS-CoV-2 infection, irrespective of clinical signs and symptoms.
3 Probable case: A PUI for whom testing for SARS-CoV-2 is inconclusive (the result of the test reported by the laboratory) or for whom testing was positive on a pan-coronavirus assay.
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:
Call your doctor, who will assess you and see whether you qualify as a person under investigation. Please do not arrive at the hospital unannounced so that they can prepare to safely and efficiently receive you.
Self-isolate at home, and avoid social contacts. If possible, stay in a specific room and away from other people in your home, and use a separate bathroom.
Wear a mask if you have to be around other people in your home and wash your hands regularly. Remember however that only specific masks such as the N95 are approved to protect you from infecting others.
If a family member cares for you, he/she should wear a face mask when they are in the room with you, and wash their hands thoroughly when they leave the room.
Doctors have been informed and trained on how and from whom they should collect specimens. When you visit the doctor, clinic or hospital, you will be asked certain questions, examined and informed whether you should be tested. If so, they will collect a specimen for testing and send this to a laboratory.
Various labs have been trained on testing for the virus and are working closely with NICD on the same.
PLEASE NOTE: Patient self-referrals will NOT be tested. You must go to your healthcare provider for assessment.
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:
Covered from which benefit?
Diagnostic testing according to agreed protocols
Treating doctor will collect specimen or private laboratory
Risk/ Prescribed Minimum
Consultations with your
At the practice
Risk/ Prescribed Minimum
Risk/ Prescribed Minimum Benefits
Defined supportive treatment and medicine
In-hospital or out-of-hospital
Risk/ Prescribed Minimum
Benefits. Formularies and other
managed care protocols apply
What if the test outcome is positive?
In the case of a positive diagnosis, you, your representative or your healthcare provider must notify us of the diagnosis as soon as possible. Your healthcare provider will prescribe the necessary care, depending on the severity of your symptoms. Fedhealth will cover out-of-hospital and/or in-hospital treatment as PMB from Risk in line with formularies and other standard managed care protocols.
What if the test outcome is negative?
If the diagnosis is negative, the related tests will be covered from your day-to-day benefits. Any consultations with medical practitioners will be covered from the day-to-day benefits available on your option. There is no need to be tested more than once, but if you do this, it will also be covered in line with available day-to-day benefits.
To recap what Fedhealth covers and from which benefit:
Only positive tests will be paid from Risk; if the test is negative, it will be paid from your day-to-day benefit.
If you test positive and have a mild case that does not require hospitalisation, any treatment will be paid from your day-to-day benefits (similar to what happens in case of the flu).
If you test positive and have a complicated case that requires hospitalisation, these expenses will be covered from your in-hospital benefit according to the benefits on your option.
Using CT scans to diagnose COVID-19
Fedhealth will NOT cover CT chest scans to diagnose COVID-19. However, CT chest scans will be covered for the management of COVID-19 positive members.
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.
Why are we asking this of our members?
We don’t want to burden the healthcare system at this time, because we need as many hospital beds as possible to be available for patients requiring hospitalisation in the case of COVID-19;
We’re all hearing about social distancing to slow down the spread of the virus. Avoiding hospitals is another way to protect yourself from possible exposure to the virus.
Mediclinic has temporarily terminated elective surgery
Following the announcement of the national lockdown, Mediclinic Southern Africa stopped all elective surgeries from midnight on 26 March 2020. This drastic measure is in line with the regulations and will also manage the risk to patients, staff and doctors as well as preserve limited stock of Personal Protective Equipment (PPE). Emergency, urgent and some semi-elective procedures will still be performed during this period. Members who have a procedure booked at a Mediclinic during the lockdown period should contact their doctor to discuss the postponement or cancellation of their surgery.
Netcare also announced that with effect from midnight 30/03/2020, all elective surgery has been postponed, provided that this will not result in the patient’s outcome or quality of life being significantly altered.
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.
Due to slight changes in the genetic material of the influenza viruses A and B, new virus strains emerge each year. So, last year’s flu shot won’t protect you against this year’s viruses. Fedhealth generally recommends that our members get vaccinated every year.
However, the flu vaccination may be limited this year. As such, we recommend that members who are at a higher risk of developing influenza and those who are above 65, try to make their vaccination a priority, whilst practicing the recommended precautions to avoid COVID-19 infection.
Tips for safely getting your flu vaccine during lockdown:
Call in advance to see if your pharmacy has a supply of the vaccine available
Schedule an appointment if the facility allows – this will reduce the time you have to spend in waiting areas and help with practicing social distancing
Although pharmacies are open during lockdown, you should ONLY go to the pharmacy if you absolutely need to and return home as quickly as possible after you’re done.
As a Fedhealth member, you and your dependants have a FREE flu vaccination benefit that’s paid from Risk, and not your Savings or MediVault and Wallet.
These flu vaccines* are covered by Fedhealth from your screening benefit (one per beneficiary per year):
· Influvac 0.5ml
· Vaxigrip Single Dose 0.5ml pre-filled
· Vaxigrip Single Dose 0.25ml pre-filled paediatric
* Important note:Vaxigrip Tetra (Nappi code: 3000826 VAXIGRIP TETRA SINGLE DOSE 0.5ML) is NOT covered by the screening benefit for the 2020 flu season. The Scheme covers other alternatives suitable against circulating strains of the virus in South Africa based on the most recent flu surveillance information provided by the WHO (World Health Organization). If you prefer this particular vaccine, it will be covered from your Savings/ MediVault and Wallet where applicable, or out of your own pocket (myFED members).
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).
Fedhealth has implemented in-house telephone and virtual consultation codes for certain healthcare professionals including psychologists and psychiatrists who do not have such codes allocated in their respective national and private coding scheme. These codes are applicable where communication technology is used to provide services to patients during the COVID-19 nationwide public health emergency, using any non-face-to-face remote communication platforms that are available to connect with patients, inter alia telephonically, Skype, Facetime or any other form of virtual communication.
The diagnosis of the patient will determine whether the consultation claim pays as a PMB or from medical Savings or MediVault (flexiFED range of options).
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.
Fedhealth offers the following services to members that can prove to be especially valuable to members during this time:
Emotional Wellbeing Programme service expanded
To assist our members with COVID-19 related concerns and provide support for psychosocial
emergencies including trauma, the Emotional Wellbeing Programme has introduced a dedicated
Crisis Support Desk. Contact them on 0860 111 646.
Using the Fedhealth Nurse Line
The lockdown is intended to make as many people stay at home as possible in order to curb the
spread of COVID-19. That’s why the Fedhealth Nurse Line is especially valuable at this time, as it
allows Fedhealth members to get medical advice from registered nurses without leaving the safety of their homes. Call 0860 333 432 to access this service, and press 3.
Speak to a personal health advisor/nurse:
To help you assess day-to-day medical symptoms;
For important health knowledge, e.g. to explain medical terms and give dietary advice;
For a complete drug database – i.e. to understand everything about a specific medication including the side-effects and dietary requirements;
For advice on poisoning and whether or not to send an ambulance if the patient is critical;
Health counselling on diseases like HIV/AIDS, cancer, diabetes and asthma and support for caregivers, as well advice on dealing with addiction;
To give you advice on stress management;
To access the Teen Line – advice for teenagers on a wide range of topics, and support for children who are neglected and/or abused.
MediTaxi is still operational during the lockdown
MediTaxi is a medical taxi service available to qualifying members in Cape Town, Johannesburg,
Pretoria and Durban. Fedhealth members who’ve had hospital authorisations can access the 24/7
MediTaxi benefit to take you to follow-up doctor’s appointments during the national lockdown, if you’ve undergone an authorised operation or medical treatment that prevents you from driving.
MediTaxi provides transport from the member’s home to the approved healthcare service provider
such as physiotherapists, doctors, specialists or a radiology practice, and includes the return trip.
Booking the MediTaxi service
When members phone to book a trip, you need to provide your a) membership number, b) date of
operation, and c) healthcare provider’s details.
To access the MediTaxi benefit
Members need to save the number *130*3272*31# for Emergency Medical Service (EMS), Nurse Line and MediTaxi as a contact on their phones (under Europ Assistance or a name you’ll remember for emergencies).
When you need to book MediTaxi, members need to choose this number and select the service (EMS, Nurse Line or MediTaxi). An SMS will be sent to the Europ Assistance Emergency Contact Centre who’ll phone you back within the agreed emergency timelines for each service: EMS – 120 seconds; Nurse Line – 2 hours; and MediTaxi – 2 hours before pick-up.
You can still benefit from Paed-IQ
Paed IQ is a 24/7 telephone advisory service available to all parents with children under the age of 14 years to support and advise on any healthcare related childcare issues. This service is also very useful during the lockdown period, since parents can contact Paed-IQ and avoid going out and risking exposing themselves and their children to an infected person in the doctor's waiting room, or the emergency rooms. Call 0860 444 128 to access this great service.
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.
When choosing a medical aid, start by asking yourself a few key questions:
What is your budget? A good rule of thumb is to budget for spending around 10% of your monthly household income on medical aid. Any more than that and your monthly medical aid bill could become unaffordable.
How healthy are you? If you have a chronic illness like diabetes or asthma, you may have higher monthly medical expenses (for things like medication and doctor consultations) than someone who doesn’t suffer from a chronic condition. If you do have a chronic illness, consider an option that gives you comprehensive cover to meet your specific medical needs. If you’re a healthy individual, don’t select a medical aid plan that covers conditions or treatments you don’t need.
Do you have a pre-existing condition? Many medial aids will impose a waiting period if you join with a pre-existing condition. This means that for a certain period after joining the medical aid, you won’t be covered for medical expenses relating to that condition.
How old are you? The reality is that the older you get, the more likely you are to develop an illness, and the longer you’ll take to recover from it. At the same time, above a certain age you’re likely to stop earning as much income as you did when you were young – and so you’d need more financial help with covering medical expenses.
What is your family situation? Whether you’re young and single, are planning to start a family, have small children, or support elderly parents, all of these factors mean you’ll have different monthly medical needs.
Most medical schemes offer a variety of plans to suit different individuals: hospital plans, for example, are the cheapest plans available because they only cover you for procedures performed if you’re admitted to hospital. Because of this, hospital plans are suited to healthy individuals with no existing health problems, and those who don’t have families or dependants. On the other hand, comprehensive medical aid plans are more expensive, but they will cover you for many more health expenses such as doctor visits, screenings, medication and out-patient procedures. These are best for people with small children, who are older, or who have medical conditions.
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.
As of the end of 2019, South Africa housed 80 different medical aid schemes, of which 59 were restricted or closed medical schemes, with just over 4 million members and 8.87 million beneficiaries. This ratio of closed to open medical schemes has been steadily decreasing over the last two decades.
Restricted or closed medical schemes are typically much smaller in membership numbers than open schemes. For example, the largest restricted scheme in South Africa is the Government Employees Medical Scheme (GEMS) which has just under 700 000 members and around 1.8 million beneficiaries. The South African Police Service Medical Scheme (Polmed), the second largest closed medical aid, has just over 175 000 members and over 500 000 beneficiaries. Compare this to Discovery Health, South Africa's largest open medical aid scheme, which has around 1.3 million members and 2.3 million beneficiaries.
One of the biggest advantages of a closed medical scheme is that because only certain individuals are included, risk exposure can be better managed and collective bargaining power means that membership costs are reduced. As well as this, the benefits can be specifically designed around the needs of that group of individuals – such as policemen who may be subjected to higher risks as a result of the nature of their work.
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.
Medical aid rates, then, are often far less than what these specialists charge, though the exact rate you’re quoted will depend on the scheme you’re with and the plan you’re on. Typically, entry-level hospital plans will have a medical scheme rate (MSR) of around 100% of these guideline prices, whereas more comprehensive plans may pay up to 300% of the guideline prices.
So, if a specialist charges 500% of the medical aid rate for a particular procedure or treatment, but your medical scheme only quotes you medical aid rates of 300%, you’ll be liable for the difference between these two amounts.
When choosing a medical aid, find out what medical aid rates the scheme will give you. This will allow you to work out what you’d need to pay in over and above to a particular health provider. In addition, using doctors and specialists within your medical aid’s network means that they’ll most likely charge at the scheme rates – so you won’t need to pay anything extra to cover the difference.
As everyone looks to reduce their monthly expenses, you may be wondering if you really need a medical aid plan, and if so, which type you need. Should you take out a hospital plan to cover procedures in hospital, or does your family situation mean that you need comprehensive cover with day-to-day benefits? One type of medical aid plan is not necessarily better than the other – it’s all about your circumstances and which option would suit you better.
The reality is that private medical aid treatment in South Africa is hugely expensive. And the alternative - public healthcare - cannot guarantee you consistent high quality care, as our public healthcare systems are under severe strain.
Getting medical treatment from a private provider if you’re ill or in an accident can end up costing thousands of Rands though, and this is the main reason that you need to have a medical aid plan. Belonging to a medical aid will mean that you can avoid having to pay large unexpected sums of money out of your own pocket, should you need medical help.
If you’re admitted to hospital, these costs could include things like:
The hospital fee
The anaesthetist’s fees
The doctor or specialist’s fees
Any take-home medication you may need afterwards
A hospital plan means that you’ll be covered for the majority of these costs (typically in full, if you use providers within your medical aid network). Comprehensive medical aid plans give you even more coverage for medical treatment outside of being admitted to hospital, for things like monthly medication, seeing the GP or a specialist for a check up, having x-rays or other diagnostic tests done.
You can also take out a medical aid plan that has a savings portion attached (called a medical savings account or MSA). This is a portion of your monthly contribution that your medical scheme saves for you on your behalf, that you can then use for any medical-related expenses, such as if your child needs to visit the GP with the flu, for example. This helps you budget a bit better, as you won’t suddenly have to cover these expenses out of your own pocket.
Overall, having a medical aid plan is really important if you want to get immediate access to high quality practitioners, treatment and medical facilities, to keep the health of you and your family in the best state possible.
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:
Current health and family situation
Do you have a pre-existing condition like diabetes or asthma? Are you planning on falling pregnant? Do you have elderly parents whose health needs you need to cover? Or, are you very healthy with no dependents? All of these will influence the type of cover you need, which in turn will have an impact on which medical aid provider you choose.
Customer service and care
It’s all very well having top notch medical cover, but when it comes to managing claims, dealing with queries, or providing advice and support to their members, you need to check that your medical aid provider will be there when you need it most. In order to do this, it’s worth speaking to other people you know who are with a certain provider and getting their feedback on their experiences. Bear in mind that online reviews can skew your perception, as consumers only tend to post unhappy stories, so do keep this in mind.
That all-inclusive comprehensive medical aid cover may seem like a very attractive option, but you need to check if your budget can cover the monthly contributions. Draw up a budget of your income and expenses each month and be realistic on how much you can afford, as there’s no point in taking out a policy you’re likely to default on. Many medical aids also offer interesting ways of cutting costs, like unlimited GP consults once you’ve reached your threshold level – so it’s important to weigh these up.
Deciding which medical aid is best for you is not a simple decision, but it is an important one. Weighing up the various factors above will help you choose a plan you can afford, which gives you and your family the unique cover that you need.
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.
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.
How long your children can remain as beneficiaries on your medical aid depends on medical scheme and plan you’re on. All schemes have to cover child dependants at the child rate until they turn 21, but thereafter, the scheme can start charging the adult dependant rate. Fedhealth, for example, offers child rates for all child dependants until they are 27 – so you’ll still be paying the same lowered premiums for your grown-up children, with the same cover provided. There are certain conditions that apply to this – to qualify for this benefit, the child needs to be still studying as a full time student (whether they’re living at home or in student accommodation), and they need to be financially dependent on you.
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.
Note that with Fedhealth, late joiner penalties may also apply to parents. These penalties vary from 5 – 75% of the monthly contribution, depending on how many years the parents have been without medical aid cover. To avoid these penalties, the main member will need to provide membership certificates to prove the previous medical aid cover that the parents have had in the past.
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. Once this waiting period is over, as an adult dependant they will then have the same level of cover as the main member, and will have access to the same risk benefits.
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.
There are generally two ways to claim for medical aid: either you can do it yourself, or your healthcare professional can do it on your behalf. Many healthcare providers ask that you settle with them first and then claim the money back afterwards. Others are willing to claim directly from your medical aid, so you don’t need to pay them first. Depending on which route you go, your medical aid will either refund the money directly into your bank account, or to the bank account of your health provider.
All medical aids have a limited time in which you can submit a medical claim. Specifically, all claims need to be submitted to your medical aid within four months from the date you received the service or treatment has been obtained. If you have a claim that falls out of that date, your medical aid will decline the payment of your claim, even if you have benefits available.
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.
Dependants – if you want to add your spouse, children or other members of your family onto your medical aid plan, you’ll need to provide the same details for them as listed above.
Previous medical cover – you’ll need to give details of any previous medical aid you and/or your dependants belonged to in the past.
Medical conditions to declare – you’ll need to disclose whether you or one of your dependants has a pre-existing medical condition. Remember that if you don’t disclose this, you could limit or be excluded from receiving certain benefits, or in some cases have your membership terminated.
Banking details – you’ll need to give these in order for your medical aid to know where to pay claims to, as well as where to debit your monthly contribution from. In most cases you’ll need to provide verification for these details, such as a copy of a bank statement and a letter from the account holder.
Your income – you’ll need to provide this if you join an option that is income banded, which means that your contribution is set based on what you earn.
After filling in these details, you’ll submit the application - at which point the medical aid scheme will consider your membership. Many medical aid schemes in South Africa allow you to do this process online, making it quicker and more convenient. Some medical aid schemes might ask for supporting documentation to be submitted with your option, and to follow the instructions they have laid out on their application form. Submitting all of the documents with the original application ensures that your membership is captured without any delays.
In some instances, the amount that your medical aid plan is willing to pay out for a medical procedure will be less than what a health practitioner charges – especially if you’re using a provider outside of your medical scheme’s network. In this case, the shortfall between your medical scheme’s tariff (MST) and the provider will need to be paid in yourself, known as a co-payment. Medical aid gap cover is short term insurance coverage that is completely separate from medical aid, and covers a portion of the co-payment that you’re responsible for.
Gap cover is designed for people who already have medical aid in place, so you can’t get a policy without having a pre-existing medical aid cover. There are many different gap cover providers in South Africa, all of whom provide different levels of cover. Some of them may cover things like hospital admissions, surgical procedures and medical scans, as well as outpatient expenses for up 500% of the MST. Others have cheaper premiums but offer a lower reimbursement percentage, and for fewer medical expenses.
You can apply for medical aid gap cover if you are under 60 years old and are already a member of a medical scheme. As with medical aid, there’s also usually a waiting period for joining gap cover and receiving all benefits. There’s also usually around a year’s waiting period for pre-existing conditions, during which time you won’t be able to claim.
Even if you have medical aid, you could be faced with huge medical bills to pay in over and above what your medical aid will cover. For these cases, gap cover can help alleviate the financial strain – especially for large medical expenses in the case of a serious illness or accident.
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.
Hospital plans are cheaper because they only cover costs related to in-hospital treatment, including surgery, ward fees or specialist fees. You won’t be covered for day-to-day expenses like GP visits, trips to the physiotherapist, medication or procedures performed outside of a hospital, so you’ll need to fund those costs out of your own pocket when they arise.
If you and your family are relatively healthy and keeping medical aid costs low is a priority for you, then a hospital plan is the cheapest way to go. This type of plan is probably not suitable if you have a chronic condition or illness that needs regular management.
Now that you’ve decided that a hospital plan is the right choice for you, how can you bring medical costs down even further?
Most medical aid companies use networks of specialists and hospitals that they have chosen for their high standards, and who offer convenient access to their members. Choosing a hospital plan that uses networks brings your medical aid costs down further, as your medical aid company has pre-arranged specific set costs for treatment with them.
There are some medical aid providers who offer affordable cover to those who have never had medical aid before, but who now want an option to protect their families’ health. Your premiums are related to how much you earn, and you can also choose not to pay for certain benefits until you use them.
With some medical aids, you can cut your premiums by 25% every month by choosing to make certain co-payments. You’ll get access to the same benefits, but pay a much lower monthly contribution by choosing to pay a fixed co-payment on any planned hospital procedures. In emergencies, you’ll still be taken to the nearest private hospital.
This website and the information contained within it is intended for information and consumption purposes only and does not by any means supersede the Rules of the Scheme. In the event of any discrepancy between this website and the Rules of the Scheme, the Rules of the Scheme will prevail. POPI act compliance information as well as the rules of the scheme are available here - Please click on the rules and annexures / POPI Compliance tab in order to access the documents. Alternatively a copy can be obtained by contacting the Fedhealth customer contact centre on 0860 002 153.