It is at this time of year that Medicare plan members must choose their plan options for the next year. With 18 health insurance plans open and hundreds of plan options to choose from, making a decision can be overwhelming, especially since members are typically not allowed to level up over the course of a year. one year of benefits. The key to making a decision is to first understand the underlying terminology and industry specific jargon. Let’s take a closer look:
Acute condition: A condition that usually lasts a short time and can be cured, such as a broken bone, ear infection, or tonsillitis. An acute condition normally goes away after treatment.
Acute medication: Medicine prescribed as a one-time treatment to rule out disease, such as antibiotics for a sinus infection or an antifungal cream for a fungal infection. Acute medications are normally paid for from out-of-hospital benefits in the case of full medical help, or from your medical savings account.
Dependent adult: Generally, a dependent adult is a person over the age of 21. They will be billed at the stipulated adult rate.
Alternative health care: Also called complementary medicine, they include therapies such as chiropractic, homeopathy, naturopathy, osteopathy, and reflexology. These therapies are regulated by the Allied Health Professions Council, and most medical assistants now support these therapies, subject to limits and sub-limits.
Year of service: Benefit years for most plans run from January 1 to the end of December, with members having the flexibility to change plan options starting January of the following year. If you join a medical plan during a benefit year, your benefits will be prorated. Most plans do not allow members to upgrade their plan options during a benefit year.
Dependent child: A dependent child is any person under the age of 21 who will be billed at the plan’s dependent child rate. The definition includes natural children, stepchildren, legally adopted children or children in legal custody of the member.
Chronic condition: Chronic disease is a life-threatening illness that lasts for three months or more and requires continued treatment such as diabetes, HIV, cancer, or asthma.
Chronic medication: Chronic medications are prescribed for life-threatening conditions such as heart disease or high blood pressure, and usually need to be taken for longer periods of time.
Co-payment: A co-payment is a fixed amount in rand that your medical aid requires you to pay out of pocket for specific treatments or procedures. Typically, user fees are charged for in-hospital procedures, scopes, scans, and radiology.
Daily benefits: These are benefits that are not covered by the hospital or the risk component of medical aid. Comprehensive medical aids provide day-to-day benefits for extra-hospital costs such as dentistry, optical consultations, GPs, and acute medications. If you have a hospital plan with a medical savings account, your day-to-day health care costs will be covered by your medical savings account. In the absence of a medical savings account, you will have to finance all of your daily health costs.
Designated Service Provider (DSP): A DSP is a healthcare provider, such as a general practitioner or hospital network, that has been engaged by a medical plan to provide services to its members. Many plans require their members to use their PSD to ensure their treatment is fully covered. When members choose to use a non-DSP, they may be required to pay a co-payment.
Disease Management Program: Most physician assistants have disease management programs, especially for common illnesses such as diabetes, kidney disease, HIV / AIDS, asthma, and cancer. The goal of these programs is to develop treatment protocols designed to improve limb health, slow disease progression, and control or reduce associated treatment costs.
Exclusions: Each medical plan has published a list of treatments and care that it does not cover. These usually include cosmetic treatment, treatment for self-inflicted injuries and / or suicide, treatment for obesity, etc.
Space coverage: Gap coverage is short-term insurance intended to cover the difference between the amount billed by doctors and specialists in hospitals, and the amount paid by your medical aid. Its role is to provide additional financial protection to medical plan members who receive treatment and care in hospital so that they are not faced with significant expenses following a hospital event.
Hospital plan: A hospital plan covers only treatment in the hospital and generally includes the cost of a movie theater, x-rays, medications, blood tests, and blood transfusions performed during your stay in the hospital. Hospital plans can range from a network option capped at 100% of the medical aid rate to full hospital coverage that pays 300% of the medical rate, so it’s always important to know what you are buying.
ICD-10 codes: A globally accepted disease classification and coding system developed by the World Health Organization that identifies diagnoses, symptoms and procedures. It stands for International Classification of Diseases, Tenth Revision.
Late arrivals penalty: Since medical aid operates on a cross-subsidy basis, those who choose not to be on medical aid earlier in life may be assessed a late arrival penalty when they finally apply for membership. When an affiliate is 35 years of age or older and has not been affiliated with medical aid before April 1, 2001, or if there has been an interruption of more than three consecutive months, the plan may charge a penalty. late membership. Depending on your age and your termination of membership, your premiums may be charged between 25% and 75%.
Treatment protocol: Managed care is used by medical plans to reduce costs, while maintaining high quality of care, and these can be delivered through provider networks, provider monitoring, drug formulas, programs. chronic disease and pre-authorization mechanisms.
Medical savings account: If your plan option includes a medical savings account, part of your monthly premium will be allocated to this fund. Funds in your medical savings account can be used to cover ongoing health care costs in accordance with the rules of the plan. Once you have used up the funds in your medical savings account, you will need to pay the daily health costs out of pocket.
Medical plan rate: Medical costs such as doctor’s, specialist’s and hospitalization fees are not regulated and service providers have the right to fairly bill for their services. However, the Department of Health has issued a pricing guideline (known as the Reference Price List (RPL)) which is used by medical assistants as a guideline when setting their rates. These medical plan rates differ from plan to plan, but in general, the most basic plan options cover hospital costs at 100% of the medical plan rate while high-end plans pay up to at 300% of the price of the medical plan.
Member family: Refers to the Primary Member and all of their registered dependents which may include a spouse, financially dependent adult children and elderly parents.
Network provider: A list of service providers, including hospitals, general practitioners and pharmacies, who have been contracted out to a medical plan to provide treatment or drugs at an agreed rate.
Aggregate annual limit: An aggregate limit is a cap on the benefits offered by a health insurance plan in a given benefit year.
Over-the-counter medications: Drug that you can buy over the counter at a pharmacy without needing a prescription from your doctor or specialist.
Pre-authorization : Most medical plans require that you obtain prior authorization before being admitted to the hospital.
Pre-existing condition: Any medical condition you have at the time of applying for medical plan membership, keeping in mind that your condition must have been diagnosed by a licensed health care professional.
Minimum prescribed benefit: The Minimum Prescribed Benefits (PMB) are a set of benefits defined to ensure that all members of the medical plan have access to certain minimum health services, regardless of which benefit option they choose. The aim is to provide people with continuous care to improve their health and well-being and to make health care more affordable. Under the Medical Plans Act, medical plans are required to cover the costs associated with the diagnosis, treatment and care of any emergency medical condition, a limited set of 271 medical conditions and 26 chronic conditions as defined in the list. chronic diseases.
Rolling Advantage: Any unused amount you have in your medical savings account at the end of a benefit year will carry over to the next year and add to that year’s MSA balance. This is called a rollover benefit.
Threshold benefit: Usually provided by comprehensive medical assistance plans, a guarantee threshold is risk coverage that kicks in after you exhaust your medical savings account. In most cases, there is a self-payment gap where members must fund their own medical aid expenses before the benefit threshold goes into effect.
Waiting times: When applying for medical aid, two types of waiting periods may be imposed. First, there is a general waiting period of three months during which no claims will be paid. Thereafter, members may face a twelve month waiting period for any pre-existing conditions they have, although this waiting period can only be applied if you are enrolled in a medical plan for the first time. times, or if you have discontinued your membership. more than 90 days. During this period, a member will have to pay the full medical aid premiums, while all medical expenses – except those related to the minimum prescribed benefits – will be for their own account.