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Capitated scheme options
A capitated product is one where the majority of the members benefits are provided by a network of hospitals, clinics or GP’s. The member does not have a free choice of provider. These products usually provide unlimited day to day cover but the cover is limited by treatment protocols and restrictive medicine lists. Some common procedures are often excluded on these plans. The choice of treatments that can be prescribed to members is therefore less. These plans usually have salary sensitive contribution tables and are particularly attractive for low income earners.

Day-to-day benefits
This refers to benefits relating to everyday out-of-hospital medical costs, such as GP visits, dentistry, optometry and acute medication.

NRPL
NRPL stands for "National Reference Price List". This is an indicator of what rates a healthcare provider will charge, and at what rate a Medical Aid will in turn pay. A Medical Aid option that pays at "100% of NRPL" will pay for procedures at the rate prescribed by the National Reference Price List. 100% of NRPL is also commonly referred to as "medical aid rates". Generally healthcare providers will charge "private rates" which can be considerably more than NRPL rates. You as the member, will be responsible for the balance of the account. Medical Aid options that pay up to "200% of NRPL" will pay twice the NRPL rate for procedures, and you will have to pay less out of your own pocket. Medical specialist services in hospital are a major cost driver and are routinely charged at up to 5 times NRHL rates. For this reason we suggest that you consider a hospital top-up product which boosts your cover in hospital to 500% of NRPL rates. These products are inexpensive.

PMB Chronic Disease List (CDL) Conditions
According to the Medical Schemes Act, Medical Aids are required to  provide unlimitedcover for 25 specified chronic conditions. Cover must include diagnosis, medication, treatment and care of these conditions. In order to manage their financial risk, schemes can however provide cover through designated service providers and impose formularies and limited lists of medicines. The 25 chronic diseases specified for Prescribed Minimum Benefits are:

  1. Addison's disease
  2. Asthma
  3. Bronchiestasis
  4. Cardiac failure
  5. Cardiomyopathy disease
  6. Chronic renal disease
  7. Chronic obstructive pulmonary disease
  8. Coronary artery disease
  9. Crohn's disease
  10. Diabetes Insipidus
  11. Diabetes Melitus Type 1
  12. Diabetes Melitus Type 2
  13. Dysrhythmias
  14. Epilepsy
  15. Glaucoma
  16. Haemophilia
  17. Hyperlipidaemia
  18. Hypertension
  19. Hyperthyroidism
  20. Multiple Sclerosis
  21. Parkinson's disease
  22. Rheumatoid Arthritis
  23. Schizophrenia
  24. Systemic Lupus Erythromatosis
  25. Ulcerative Colitis

Scheme solvency
This is an indicator of financial stability. The Medical Schemes Act requires Medical Schemes to have a minimum solvency margin of 25% of the annual premiums collected by the scheme.

Open Scheme

An open medical aid scheme is accessable to any member of the public.  Anyone can apply to join an open scheme.

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