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l Understanding the Concepts
l Understanding the Concepts
SAB Medical Aid aims to provide you with excellent and uncomplicated service. The following terminology and concepts explain how your benefits and cover for medical expenses work.
Be cognisant of the frequently used abbreviations which are repeated throughout the documentation and communication regarding your membership benefits and cover.
Comparison of Options
About Prescribed Minimum Benefits (PMBs)
Prescribed Minimum Benefit Conditions
In terms of the Medical Schemes Act, 131 of 1998 and its regulations, all medical schemes must cover the costs related to the diagnosis, treatment and care of:
- Any life-threatening emergency medical condition
- A defined set of 271 diagnosis
- 26 chronic conditions.
The cover for the treatment of these conditions is known as the Prescribed Minimum Benefits (PMBs).
All medical schemes in South Africa are obligated to include the Prescribed Minimum Benefits in their health plans. However, members must meet certain requirements before they can benefit from the Prescribed Minimum Benefits.
The three requirements are:
- The medical condition must be part of the list of defined PMB conditions.
- The treatment needed must match the treatments in the defined benefits on the PMB list.
- Members must use Network Providers. However, in the case of life-threatening emergencies this does not necessarily apply.
Additional information about Prescribed Minimum Benefits
This is only available to the SABMAS Comprehensive Option.
We allocate your Medical Savings Account (MSA) quarterly. You can use it for some medical expenses, including co-payments and discretionary medical spend (such as over-the-counter medicines and fees in excess of the Scheme Rate).
Chronic Benefit
Click here to find out more about the Chronic Illness Benefit.
Scheme Rate
This is the rate set by SAB Medical Aid at which claims for services by healthcare providers (hospitals, pharmacies and GPs) are paid.
Limits
There are some healthcare services such as dentistry that are subject to annual limits. It is important for you to familiarise yourself with these limits and to track your usage. SABMAS Medical Aid members are able to do so via this website once they have logged in.
Hospital cover
This is the cover you get when you are admitted to hospital for emergency and planned hospital admissions. You have to get authorisation from SAB Medical Aid for your hospital stay. Your hospital cover is made up of your hospital account and related accounts. A related account is an account from your treating doctor, anaesthetist and any other approved healthcare services such as pathology or radiology.
Day-to-day cover
Day-to-day cover includes your visits to healthcare providers out of hospital, radiology, pathology and medicine purchased for everyday use. We cover your day-to-day healthcare services from the relevant benefit limit, overall annual limit or Medical Savings Account (only applicable to the Comprehensive Options) depending on the healthcare services you are using.
Surcharges
Some of your benefits are funded at 80% of the Scheme Rate. In these instances, we will pay the claim at 100% and the 20% difference will be paid as follows:
- From your Medical Savings Account, if you are on the Comprehensive Option and have funds available
- If you don’t have funds available in your MSA, or if you are on the Essential Option, the amount will be:
- Deducted from your salary by your employer or
- Deducted as a debit order from your bank account if you are not employed by one of the employer groups, for example a pensioner.