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  • National Health Insurance of South Africa (NHISA) & Medical Aids: What you Need to Know

National Health Insurance of South Africa (NHISA) & Medical Aids: What you Need to Know

24 February 2016

The NHISA has a 14 year roll out plan, but that doesn’t mean we shouldn’t understand the details as well as the impact on medical aid and health insurance scheme members.

Many South Africans are unaware that there is a difference between medical aid and health insurance, which may cause issues when one finds themselves in need of medical attention. Sue Cogswell, Director of Healthcare Benefits at BDO, makes the distinction between medical aids and health insurance: “In the broad aspect, medical aids are private organisations that provide access to private healthcare for a monthly fee, are governed by the Medical Schemes Act and have a regulatory body called the Council for Medical Schemes. There are certain procedures or conditions called ‘prescribed Minimum Benefits’ that medical aids have to cover. There are defined waiting periods or exclusions, and applicants cannot be refused cover,” she states. “Health Insurance, as proposed in the National Health Insurance plan, is a system of healthcare financing that will ensure everyone has access to appropriate, efficient and quality health services.”

“The right to access quality health services will be on the basis of need and not socioeconomic status ,” states Cogswell. “The NHI will ultimately deliver a comprehensive package of health services. All South Africans will have access to needed preventative, curative, rehabilitative and palliative health services that are of sufficient quality and are affordable, without exposing them to financial hardships,” she concludes.

There are also current medical insurance plans available, but these pay a stated amount of money for certain stated procedures/conditions & will usually depend on the severity of the condition, whereas medical aids will pay the cost of the procedure/condition. The cost will be determined by the medical aid rate payable by your plan.

With only 17% of the South African population belonging to a medical aid, according to the National Development plan 2030, the promises of this health service will do wonders for the 83% of South Africans who are at risk. However, this majority will have to wait a while (it has a 14 year roll out plan) before the NHI becomes an option, and for those looking to switch their medical schemes for cheaper options, it is advisable to have a discussion with a Healthcare broker as the process can be strenuous.

Knowing that there may be a gap within your medical aid re-imbursment, Cogswell urges people to consider a GAP cover. GAP cover is a short-term insurance policy that can be taken out in conjunction with any medical aid. Depending on the plan, it will cover the difference in hospital costs between what the specialists charge and what the medical aid pays. It can also pay co-payments for in hospital procedures. This means that surprise charges that usually flair up after hospitalisation may be covered. “It is a very worthwhile cover to have as medical aids are reducing their benefits, creating more gaps that the member has to fund,” advises Cogswell.