admin
Correspondent
The old adage your health is your wealth rings true in the quest to find the best medical aid.
The selection of the appropriate medical aid cover can only be ensured by a keen understanding of how medical aid works.
This article will demystify the inner workings of the medical aid industry to empower you to make the best decision for your family or business enterprise.
The article will outline the following:
1) The decision criteria for selecting a medical aid and the joining process.
2) The rationale of waiting periods.
3) Premium payments.
4) Accessing Healthcare facilities.
5) Claims submission and processing.
6) Policy updates and renewals.
7) Terminating the account Joining.
The key decision factors for consideration for selecting a medical aid scheme from the various players on the market are one’s affordability and healthcare needs.
Medical Aid providers have a variety of plans to match the financial circumstances and medical needs of a wide spectrum of prospective members.
After making a choice, one is required to complete an application form detailing personal details and medical history. One may join a medical aid on an individual basis or under a corporate arrangement.
In line with common practice in the medical insurance industry there is a maximum age at joining and underwriting is conducted.
This may include a medical examination or an assessment of medical history and a requirement to disclose pre-existing medical conditions.
Once an application is approved, the medical aid issues a medical aid policy, and the individual becomes an official member with access to the selected plan’s benefits.
Waiting periods: Medical aids apply waiting periods on benefits which a member may access after a set time-frame. The period a member has to wait differs for individual and corporate policyholders.
These can vary by category of medical service — commonly known as discipline, such as maternity, optical, dental, or specialised services. Some waiting periods may be waived depending on the medical aid society policy or insurer’s assessment of the risk posed by the member. The waiting periods are communicated at the point of joining the medical aid.
Understanding and evaluating these terms is crucial for making informed decisions about healthcare coverage.
Premium Payments: Medical contributions are paid in advance and are usually paid on a monthly basis as defined in the policy. The contribution amount varies depending on the chosen plan.
It is critical that the member pays contributions in a timely manner to keep the policy active and ensuring uninterrupted access to healthcare services.
In the event that a member fails to pay premiums before the cut off date, the account is suspended and the member will not be able to access healthcare services.
Most medical aids suspend accounts for non-payment on a monthly basis. In the case that payments are not made for a period of time, usually up to 3 months, the policy lapses and the account is terminated and cover ceases.
In the case of a lapsed policy and the member wishes to resume it, the member will need to renew their policy and waiting periods may apply on re-joining.
This means medical aid is valid when premiums have been paid. This principle is applicable in all instances despite the duration that the account would have been running before.
Accessing Healthcare Services
After enrolling in a medical aid plan and payment of contributions, members will begin to access healthcare services as soon as applicable waiting periods end.
Members are usually issued with a medical aid card and have their finger prints enrolled biometrically to enable them to access services.
These services may include doctor visits, hospital admissions, and buying prescription medications at the pharmacy using the medical aid card.
The extent of coverage for various services is typically outlined in the scheme rules and under each plan both in monetary terms and nature of services to be covered.
The scheme rules are shared with members through their representatives — principal members and employers and individuals.
Members may engage the medical aid provider to gain an understanding of the terms and conditions of their policy to ensure adherence.
Claims submission and processing
When a member receives medical services, a claim is submitted to their medical aid by the healthcare service provider.
The medical aid then processes the claim and pays the healthcare provider within a period less than 30days from date of receipt of the claim.
The claim initially goes through an assessment process to establish its authenticity before payment. In instances where members make an upfront cash payment to access health services, a member may submit a claim form to initiate the refund process.
This process generally involves providing documentation and receipts related to the services received which are either physically or electronically submitted to the medical aid.
The medical aid then reviews and processes the claim based on the scheme rules and benefit limits as per the member’s plan. Depending on the 3 plan, all the medical expenses can be paid, or a shortfall may occur.
In most cases, the benefit limit is known at the point of seeking service and the member is required to pay the shortfall before the claim is submitted to the medical aid provider.
Where reimbursement is being made to the member, the claim is also processed based on the scheme tariffs and payment is directly to the member. Claims payments are guided by the Association of Healthcare Funders of Zimbabwe (AHFoZ) Tariff.
This is a scientifically determined Tariff meant to ensure that the Tariffs that are viable for healthcare providers and affordable to contributing members.
In some instances, service providers claim within that Tariff and do not charge shortfalls from the patient, whilst in some instances some healthcare service providers charge above that Tariff and collect a shortfall from the patient.
The shortfall component is not refundable by medical aid. However, the receipts may be included with Tax Returns for Tax relief by ZIMRA.
Whilst there are other reasons for shortfalls, the most common has been the exchange rate disparity for ZWL Accounts.
Whilst some providers would chase the parallel rate, member contributions are collected once in advance and cannot be adjusted to chase the exchange rate through the month.
Policy Updates and Renewals
Medical aid policies are periodically reviewed in line with changes in the economic environment such as cost of medical services.
The adjustments are also made to align with evolving healthcare needs and other factors.
Regularly reviewing the policy ensures it still meets one’s requirements. Members may make updates or changes to their policies, such as
adding or removing dependants or upgrading/downgrading from one plan to another. Similar to short term insurance, medical aid is regularly renewable, monthly, through the payment of contributions and annually when full annual benefits that appear on the benefits schedule are reinstated by the medical aid society.
Termination
If a member wishes to terminate their medical aid plan, he or she will need to follow the provider’s specific termination procedures. This usually involves providing written notice within a certain timeframe and complying with any other requirements outlined in the policy.
Termination effectively closes the contract and ends the association with that particular medical aid provider. Some policies pay benefits on termination such as the balance in the member’s savings account where applicable.
In instances where a member is blacklisted for committing Fraud, this information is shared amongst other Medical aid societies under AHFoZ to warn them of the potential risk before admitting that member onto their plans.
4 Conclusion
Following the outlining of the key aspects of how a medical aid works, it is critical to note the following
The operation of medical aid involves a sequential process starting with the selection of a suitable plan, understanding waiting periods, and making regular premium payments.
• Access to healthcare services becomes possible once waiting periods have been served by the member
Claims are submitted and processed in accordance with the plan’s rules, and policies can be updated and renewed as needed.
Termination of a medical aid plan follows specific provider procedures, effectively closing the contract.
AHFoZ is a representative body for the medical aid industry in Zimbabwe www.ahfoz.org
Online Reporter