13/11/2024
Howwwzitttt SC Peeps 😎🐬🏖️
I’m desperately sorry for this VERY VERRRRY LONG post regarding MEDICAL AIDS VS MEDICAL INSURANCE…but I URGE you to please read it carefully and all the way to the end…👇🏼⬇️
We have spent a lot of time putting this one together and it is filled with information that is of the UTMOST importance to YOU and your loved ones regarding medical aids, insurance, etc.
So, you have all either received the email or heard 🧏🏻👂🏻 via the grape vine, that Medical Aids are going up by up to 10%...and there’s not a single person that has not been worried 🥴🤔about how they are going to manage to keep their Medical Aids.
Some want to come off them, some want to go to a lower plan, some are considering going onto an Insurance plan…
Here we go….
I AM BEGGING YOU, cut on ANY other expenses 🤑💸but please don’t go off your Medical Aid…and PLEASE DON’T go onto anything called a MEDICAL INSURANCE.
Companies are luring you with promises of EVERYTHING being covered…but trust me, we have dealt with these Insurances 😨 and if you DON’T read the fine print…(and let’s be honest, who ever DOES read the fine print…there’s just too many pages, so we just skip to the end and sign 📃📝)…well then you are in for some scary surprises along the road and the rose coloured glasses 🤓suddenly gives you double vision and just makes your heart sink right into your shoes 👞👠…
So let me try and give you a BASIC breakdown…and hopefully you’ll think twice…(And yes, I know its a long read...trust me, its BASIC).
So what are the Differences between a medical aid and medical insurance...⚖️
MOST IMPORTANTLY is that you need to KNOW, YOUR Medical Aid PLAN, read the emails 📩📬 you receive, forward communications you get from them to us, so that WE know what is offered, and don’t sign up for anything unless you’ve discussed it with us. Trust me peeps, we see the anguish and tears 🥹 and frustration 😖🫤when I can’t offer a patient help, or if they need to drive to Durban 🏭🏥 to be admitted there. So most importantly what I want you to take from this writing is:
- KNOW YOUR SPECIFIC PLAN 💭🤔and make sure WHICH HOSPITAL 🏥 you are allowed to go to
- Know if your plan will cover your condition or conditions 🫀🩺👂🏻 and find out how we need to apply for it...?? Is it forms 📄we need to fill in or do we need to phone☎️🤳🏻 somewhere?
- KNOW IF YOU NEED PRE-AUTH requested by us before you can see a specialist?
- Please make sure which PROCEDURES are covered for by your medical aid, for instance, can you have a Mammogram yearly, are you allowed blood tests 💉once, twice or 3 times a year, are X-RAYS🩻 paid for, etc…
- Once you’ve applied, an email 📧💻will be sent to you stating what specific special examinations you’ll be allowed in a year…so forward that to us, so we can load it on your file so that we can also be sure to help you in the best possible and financially viable way. GPDRZEE@GMAIL.COM
- Know which blood lab you are allowed to use…for instance, BONITAS IS ONLY ALLOWED TO USE AMPATH…!! Keyhealth ALSO has to go to AMPATH. It is not our fault if you go to the wrong lab and your tests are not paid for 😥
- MAKE SURE IF YOU NEED TO NOMINATE ME AS A PROVIDER 👩🏼⚕️🥼 before you can come see me, otherwise you will be liable for the account…in other words, see if you need to nominate a DESIGNATED PROVIDER and please do so, and then also get a CALL REFERENCE NUMBER for that conversation otherwise we have no foot to stand on.
- DISCOVERY KEYCARE members, please remember that you need to nominate me as your provider ONE MONTH 🗓️📆BEFORE you come and see me (if you haven't already done so)
- And also make sure you know the exclusions, for instance, we had a lady on Fedhealth that desperately needed a hip replacement but the fine print only allowed for one should you BREAK IT IN AN ACCIDENT…so although her hip joint was bone on bone 🦴🩻 and she was in absolute agony with pain, barely able to move, they were not willing to help because it was age related and not due to an accident….READ THE FINE PRINT 👀👓🥸
- Find out what the formulary YOUR MEDICAL PLAN works on…?? A FORMULARY is the EXACT mediction your medical aid WILL pay for, but its VERY difficult for me to access that info in 15 minutes and get through the History, examination, diagnosis and scripting.... 🙄😫! If you are able to come to me and say, HERE, you need to give me this, this or this, or even just hand me a bunch of papers, or forward us the document, then I will have a rough idea of which medication might be paid for if I script it... 📝🖋️☺️🤩
Unfortunately, patients are under the impression that we should just know it… peeps, THERE ARE MORE THAN 1️⃣9️⃣0️⃣ DIFFERENT MEDICAL AID PLANS…It’s near impossible for me to know it all off hand and having to search for it takes more than 15 minutes. So please do YOUR bit and get that list, keep it safe, and bring it along when I see you 🤗👐🏻.
Also, NOT ALL MEDICAL AID PLANS GIVE THE SAME COVER…so its not a question of a medical aid is a medical aid….:
- MedElect Compact is ONLY allowed to go to Margate Netcare Hospital in Margate,
- BONCAP is only allowed for admissions at Hibiscus Hospital in Port Shepstone
- Momentum Custom Associated STATE is a medical aid that does not ⛔👎🏼😑 allow for me to apply for your chronic medication! If you WANT your chronic medication for free then you need to go to STATE (as it says in the name).
Please also note as well, that even if you ARE on a GOOD medical aid:
· You will still pay for Gastric or Colonic Scopes and that comes to R5000+
· Specialists often charge cash
· KEYCARE does not cover Spinal/Back or any form of Brain surgery
· Generally you are allowed 1 mammogram every 2 years – although you might be told yearly – PLEASE check with your medical aid
· SMART plans are for the METROPOLITANS (BIGGGGG CITIES 🌆🏙️) and there is only ONE Doctor on the SC that you can see and NO HOSPITALS we could admit you to…you HAVE to TRAVEL 🛄🛻 to Durban
· Coastal plans again, is designed for COASTAL towns (🏄🏼♀️🏖️), so should you find yourself in the city you might have a co-payment before you are allowed to be admitted in, lets say Gauteng or Bloemfontein...so be aware!!
· Delta plans, complete OPPOSITE of COASTAL plans, are ONLY used for INLAND, not on the coast, so should you be on this you’ll have co-payments 💵🫰🏻at any hospital or doctor on the coast...!!
· If you have been OFF a medical aid for more than 5 years then you’ll be paying a higher premium…So if you have gone OFF your medical aid, please get back onto one ASAP 🙏🏻🥹
· If you HAVE approved Chronic Medication and you CHANGE from one medical aid GROUP to another, you might have anything from a 3 month to 1 year waiting period before they’ll cover you for that condition. So please think carefully 💭🤔before doing that, for instance, if you’ve had stents and you now change your medical aid, you might have a one year waiting period, and SHOULD YOU have a heart attack in that time, YOU WILL NOT BE COVERED by your medical aid!!
Just a side note here…and I know it seems silly telling you this, but it is actually a little confusing:
- MARGATE NETCARE Hospital is behind the HIBISCUS Mall – THAT IS NOT THE HIBISCUS HOSPITAL
- Shelly Beach Hospital is across the road from the South Coast Mall, close to the Highway.
- HIBISCUS Hospital is in Port Shepstone, across the road from the Port Shepstone Provincial Hospital.
So it is really important that you find out from your medical aid, exactly WHICH hospital 🏥 you are allowed to go to as there are plans that only allows you to be admitted in Durban…Not one of the hospitals on the SC accept them. This responsibility lies on you 🫵🏻 to know…and you are more than welcome to argue with me on the fact that YOU NEED TO KNOW, but this is stated in the HPCSA documents…IT IS THE PATIENTS RESPONSIBILITY TO KNOW, NOT THE DOCTOR's responsibility.
Ok, so lets jump in and I’ll try and keep this short….(which I’ve already not managed but I sure hope you’re still reading)….
Medical aid:
· Medical aids cover MOST medical emergencies and planned procedures if done IN hospital. Please note, this is depending on your SPECIFIC plan, and your plan also determines your ALLOWED HOSPITAL. Having said that though, they DO COVER a lot more than an insurance … In most cases, an INSURANCE would pay for an ACCIDENT…so if you’re in a car accident, they will pay up to a limit which is somewhere between R15k and R25k (Which really only covers your Casualty Visit and from there you’ll be transferred to a STATE Hospital…in our case, you’ll be going to Port Shepstone Hospital 🚑)
· Medical aids generally have very high or no overall annual limits on private hospitalization cover…!! Depending on your plan, it might even be unlimited for IN hospital benefits. These factors set the starting price for medical aids higher than that of medical insurance products. An INSURANCE PLAN would allow for stabilization and again you’d be transferred to a STATE facility.
· Depending on your Medical Aid PLAN, you MIGHT have a medical savings 💰💳which you can use to buy medication, pay for your physio sessions, podiatry, doctors visits (plan dependant) and most of the other ‘stuff’ medical insurances don’t pay for. PEEPS, PLEASE DON’T GET LURED IN BY “ALL DOCTORS VISITS PAID”…most likely in the fine print you only have a few visits to certain DESIGNATED providers and most specialist visits DEFINITETLY WON’T be covered…let’s not even discuss admission...🧐🙈
· On most Medical Aids, you can see any GP of your choice (exception for NETWORK ONLY plans where you need to NOMINATE YOUR DOCTOR BEFORE you go and see them…and please note, in some cases, your nomination is only valid from the FIRST of a month…it’s not applicable immediately). On INSURANCE plans you are STRICTLY AND SOLELY LIMITED TO NETWORK ONLY DOCTORS and there are very few of them. PLUS, and you are probably not going to believe me, but we feel quite despondent when we know you need an admission, and we KNOW you are not covered 😢😪. And the worst is then seeing the shock 😱🫢on the patients face because they were told that it’s JUST LIKE A MEDICAL AID. PLEASE PEOPLE, it is NOT like a medical aid….
· Just on another note…patients are all under the impression that Medical Aids or for that matter Medical Insurances will cover you for XRAYS and Lab tests and CT Scan’s etc…PLEASE KNOW YOUR PLAN and KNOW what you are allowed…it breaks my heart when a patient says to me the specialist says I need a CT Scan but my plan doesn’t pay for it, or I need a hip replacement but on my plan its only allowed if it is trauma related…READ THE FINE PRINT, PLEASE!
· All medical aid products offer a set number of PMB benefits (fancy word for CHRONIC Conditions).
This cover includes 270 in-hospital, life-threatening procedures and 26 listed chronic conditions. Having said that, please note that for MOST of these “CHRONIC CONDITIONS” you actually need to see a Specialist to get the medication on your chronic treatment…As a GP, I am not able to do it.
· Chronic Conditions I CAN apply for your chronic medication is:
o Asthma
o Hypertension or Blood Pressure
o Diabetes
o High Cholesterol
o Underactive Thyroid
· Conditions you NEED to see a SPECIALIST for to get your medication approved as chronic:
o Emphysema or COPD - Pulmonologist
o Depression or Bipolar – Psychiatrist
o Epilepsy or Multiple Sclerosis – Neurologist (of which there is NONE on the South Coast)
o Cardiac Failure or Chronic Ischaemic Heart Disease – Cardiologist or Physician
o Chron’s or Ulcerative Colitis – Surgeon
o Rheumatoid Arthiris or Systemic Lupus – Rheumatologist
So, here’s a little secret…!!! Should you go to see your specialist, PRINT the CHRONIC APPLICATION FORMS 📄related to your medical aid and plan, before you go to him or her, and ask them to fill it in📝✒️ while you’re sitting in front of them…success guaranteed.
· There is also medication that I can under no circumstances, get onto chronic, no matter your plan, such as:
o Sleeping pills 😴🥱
o Cholesterol medication that is not just a statin, such as Vusor or Crestor or Zuvamor. They are NOT APPROVED ON ANY CHRONIC FORMULARY
o Anti-inflammatories will only be approved if you have been diagnosed with RHEUMATHOID ARTHIRIST, Osteoarthritis does NOT count. So Celebrex or Coxflam or Tramacet or Targinact are NOT medication I can apply for.
o Prerica or Nurika or Lyrica
o Contraceptive medication
o Some Medical aids allow some of the Hormone Replacement treatments but their list is limited and it is also only under certain circumstances.
Remember, the fact that YOU take it every day 🌞, and have been for the last how many ever years, does not CLASSIFY IT AS CHRONIC…it only means that you take it daily…
· The Medical Schemes Fees Tax Credit applies to any taxpayer who contributes towards a registered medical scheme, which means that you can apply for a TAX REBATE…but that ONLY APPLIES IF you are on a MEDICAL AID, NOT for a MEDICAL INSURANCE.
· VERY VERY IMPORTANT – I need you to understand that ALL CORE plans MIGHT cover you for 4 visits ONLY, if you have a valid PMB (CHRONIC) condition and you are registered for it!! By Registered I mean that your plan is AWARE of the fact that, you have, let’s say High Blood Pressure and they have approved the treatment of said condition…other than that, they do NOT PAY FOR MEDICATION. I also can NOT refer you to a specialist and any specialist visit will be out of your own pocket and you might only be covered for CERTAIN hospital admissions…and again, only up to a certain amount…
So again, I urge you, make sure of all these small details before you sign up for an insurance plan…Find out if they would cover you in full, for treatment in a PRIVATE facility on the SC if for instance you had a heart attack, or Gall Stones or your appendix burst and for exactly what amount. Because 2 or 3 days in hospital can easily add up to about R100k…just food for thought.
So what do Medical Insurances actually cover…?? And this is the misleading part…
· They ONLY cover in case of an accident / emergency where treatment in hospital is needed BUT YOU ARE ONLY GIVEN A LIMITED AMOUNT per event. And trust me, R15000 barely gets you past Casualties. BE SURE that you are very aware of what they are willing to cover and how much. Accident cover doesn’t mean that if you are in a car accident and you break your leg, or have a heart attack or stroke, that you can go to a private hospital and be treated there in full…you can be STABILIZED at a private hospital to the value of X Rand (however much that might be) and after that you’ll be transferred to a STATE facility.
· If you need investigations for non-emergency and non-accidental events in hospital such as colonoscopies or swallowing a camera for your ulcer, or even going for an US for your shoulder, please note that they DO NOT cover it.
· Also, you cannot be admitted for any planned procedures such as a hip replacement or a hernia repair either…They only cover for accidents…
I’m so sorry I keep repeating myself, I sound like a broken record, but I need everyone to understand it CLEARLY…esp. with the price hikes ↗️📈happening with medical aids and due to the fact that increasing or decreasing your plan needs to happen in December. I have had so many people tell me that they are moving to an insurance plan, because its better than nothing….NO peeps, its NOT better….
· Medical Insurance can cover GP Doctor visits if your GP is on their designated network, but most insurances require you to get authorisation before you visit the doctor. That Auth ONLY covers the consult, and NO EXTRA procedures, such as injections or ECG’s or excisions of lesions, and not any medication either….for all of these you would have to pay!
· If you need to see a SPECIALIST DOCTOR, such as a surgeon or Orthopaedic, SOME of the Insurance plans (again, depending on which one you are), might only cover ONE 1️⃣visit and ONLY if you have preauthorisation’s and motivations from your network GP. The issue is, once you’ve seen the specialist and you need to go to hospital, that admission WOULD NOT be covered, unless it is life threatening (emergency)…and AGAIN I say, PLEASE NOTE ONLY UP TO A LIMITED AMOUNT!! You will be liable for the rest out of your pocket. Any follow ups with the specialist would unlikely be covered (dependant on what option and amount you get).
· PMB (Chronic) conditions are limited to what your medical insurance chooses to offer. They are not enforced to offer PMB cover. Some may only cover 8 to 12 different Chronic conditions. You may only collect your medicine IF it is on their formulary and ONLY at designated pharmacies on their network.
In short, it comes down to this…
STOP 🛑✋️DELETING THE EMAILS YOU GET FROM YOUR MEDICAL AID…READ 📚👓them carefully until you understand them…if you don’t understand what they are saying, then send them on to us so we can help in informing you as to what we can help you with….
And then the part that lies closest to my heart…PLEASE NEVER EVER GO OFF YOUR MEDICAL AID, thinking that you’ve never used it or needed it…just in the past 2 years I have had more than 10 patients whom this has happened to and then they suddenly develop Cancer, or have a stroke or break your hip…and it breaks my heart when these patients then say, I can sell my car 🚗or bond my house 🏠but I’m NOT going to PSH.
Please rather quit smoking 🚬or drinking 🍻, or live a simpler life…but what ever you do, please never STOP your medical aid!!
I hope what I have said makes sense and explains things a little better for you!!
Loads of love.
Dr Zee, Caz and Courtz
