FREQUENTLY ASKED QUESTIONS

Welcome to the Profmed Medical Aid Frequently Asked Questions (FAQ) section! Here, we aim to provide you with clear and concise answers to common queries about medical aid services. Whether you’re a member, a potential member, or simply seeking information about our offerings, you’ll find the information you need right here. We understand that navigating the world of healthcare can be complex, so we’re here to simplify it for you.

A medical aid is a health insurance program that provides financial assistance for medical expenses. Originating in South Africa, the term ‘medical aid’ specifically refers to private health insurance schemes that offer coverage for hospitalisation, surgeries, medications, and sometimes additional benefits such as preventive health check-ups. Members of a medical aid pay monthly premiums in exchange for coverage, ensuring that their medical bills, either in full or part, are taken care of depending on the specifics of their chosen plan.

Benefit options refer to the different packages or tiers of coverage that a medical aid or insurance provider offers to its members. Each benefit option comes with its own set of features, such as the level of hospital care covered, the range of medical treatments included, and the types of specialists accessible under the plan. The cost of the premium usually correlates with the comprehensiveness of the coverage, with more extensive benefit options typically commanding higher monthly premiums.

Gap cover is an insurance product designed to cover the difference or ‘gap’ between what medical professionals charge for their services and what medical aids or insurance policies pay out. Medical practitioners can sometimes charge rates that exceed the maximum amount a medical aid scheme is willing to cover. In these cases, without gap cover, patients would have to pay the difference out of pocket. Gap cover acts as a safety net, ensuring that members don’t face unexpected and potentially substantial medical bills.

A Designated Service Provider (DSPN) is a healthcare provider or group of providers who offer services to medical aid members for the diagnosis, treatment and care of medical conditions, including PMB conditions. Using a DSPN ensures that you receive the most appropriate treatment to facilitate better outcomes. If you use a non-DSPN, you will be liable for any co-payment over and above what is charged by the DSPN.

Reference pricing is a managed healthcare tool that is applied when purchasing medication. Profmed applies a generic reference pricing model to acute medicines, and both generic and therapeutic reference pricing to medicines used in the management of chronic conditions on the Condition Medicine List (CML). The reference price differs from one option to another. If the cost of the medication you are using is more than the applicable reference price, you will be required to pay the difference between the reference price and the actual cost of your medication at the point of sale.

To assist you in avoiding a co-payment, make use of the medication search functionality on the Medikredit website at www.medikredit.net.

The Chronic Disease List (CDL) is a prescribed minimum benefits list that ensures all medical aid schemes fund the cost of the diagnosis, medical management (consultations and procedures) and medication of a specified list of 26 chronic conditions.

Chronic conditions refer to a list of conditions that are covered in full in terms of the medical aid’s rules if services are rendered according to the medical aid’s benefits, treatment plans and protocols, CDL medication lists, and claimed with the correct diagnostic (ICD-10) codes.

These conditions are covered on all of Profmed’s options, but benefits will be more or less restrictive depending on the benefit option that you have chosen.

Prescribed Minimum Benefits (PMBs) are covered by Profmed medical aid scheme. PMBs are a set of defined benefits that ensure all medical scheme members have access to certain minimum healthcare services, regardless of the benefit option they have selected. The Medical Schemes Act stipulates that schemes must cover the costs related to the diagnosis, treatment and care of:

  • any emergency medical condition
  • a list of 270 PMB medical conditions (defined in the Diagnosis Treatment Pairs – DTPs), which is available on the website of the Council for Medical Schemes at medicalschemes.com.
  • 26 chronic conditions defined in the Chronic Disease List (CDL).

The 270 PMB conditions are not required to be registered or authorised with the Scheme. Treatment and consultations for these conditions are identified by the ICD-10 code that is provided by the medical practitioner on the claim.

Authorisation is required for the 26 chronic conditions, and the additional conditions listed per option on Profmed’s Chronic Disease List (CDL), in order to qualify for funding from the Chronic Medication benefit. Your doctor or pharmacist must authorise your chronic condition by calling SwiftAuth on 0800 132 345. These conditions are covered on all of Profmed’s options, but benefits will be more or less restrictive depending on the option that the member has chosen.

Chronic medication is funded from the Chronic Medication benefit, subject to available funds. The consultations, radiology and pathology related to these chronic conditions are funded from the available day-to-day benefits. Once day-to-day benefits are depleted, benefits will continue to be funded from risk.