Medical aid frequently asked questions

A self-payment gap is when you have used up all your medical savings and then need to fund your health expenses from your own pocket.

For example, let’s say you have R3 000 to use on day-to-day medical expenses for the year. If you use up this amount, you move into the self-payment gap territory. This self-payment gap varies according to your family size. The more dependants you have, the bigger the self-payment gap. But, it also takes longer to get there, as your contributions would be higher than those of a single member.

Once you have reached your threshold, you move into the above-threshold benefits where the medical scheme pays for your everyday medical expenses. This is only applicable on our Extender Option.

Yes, the Scheme will still cover chronic medication and hospitalisation.

Yes, it is important to continue submitting your claims, otherwise we will not know that you have passed the self-payment gap and qualify for the above-threshold benefits.

Yes, but only if you belong to a closed medical scheme and you are retrenched, or made redundant, or you resign from the company. An open scheme can only terminate your membership if you do not pay your contributions, or if there was fraudulent transactions or claims.

You can submit claims for medical treatment up until the day your medical scheme membership expires. If you gave written notice of your intention to end your membership on the 31^st of December, and you go to the doctor on that day, you can still submit a claim for that doctor's visit. Anything after midnight that date will not be processed.

No, as that is not legal. Claiming twice for the same medical expenses is seen as fraud. It is important to make sure when you are moving medical aids that you terminate your membership with the current medical scheme before you become a member of the new medical scheme.

You can either speak to a financial adviser, or contact various schemes to get more information before you make your choice. Assess your needs first so that you can choose the option that will give you the best coverage for your needs. For example, if you have eye problems, you won't choose a scheme that only allocates R200 per year for glasses. If you're fairly healthy and don’t get sick very often, it would be beneficial to choose a scheme with low day-to-day benefits, but good hospital coverage. Make sure to read the fine print.

Usually, a couple options from a medical scheme have a medical savings account or MSA. This is a percentage of your monthly contribution, up to a maximum of 25%. This is used to pay for day-to-day medical expenses. Certain sub-limits still apply. When your MSA is depleted, you will need to pay for your day-to-day medical expenses out of your own pocket.

It is important to note that chronic medication and hospitalisation costs are not paid out from your MSA. Funds in the MSA that is not utilised, is carried over to the next year. Should you resign from the scheme and you still have funds in the MSA, this will be paid out to you.

Download the Momentum App so that you can:

• Find a network hospital.
• Find an associated provider.
• Submit and track your claims.
• Get pre-authorisation for Health Platform Benefits.
• Check your balances for HealthSaver, Personal Medical Savings Account, HealthReturns, and Active Dayz.
• Calculate your HealthReturns.
• Get your own statements and tax certificates.
• Book a health or fitness assessment.