Important concepts and terms to understand

The terms and concepts explained below are to help you get a better understanding of your cover for medical expenses as a member of SAB Medical Aid. Please note the abbreviations, as you may come across them in other documentation or communication regarding your membership benefits and cover.

Comparison of Options

Option types

 

 Essential Option

 Comprehensive Option

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 have to cover the costs related to the diagnosis, treatment and care of:

  • Any life-threatening emergency medical condition 
  • A defined set of 270 diagnoses
  • 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 have to include the Prescribed Minimum Benefits in the health plans they offer their members. There are, however, certain requirements members must meet before they can benefit from the Prescribed Minimum Benefits. 

The 3 requirements are: 

  1. The condition must be part of the list of defined PMB conditions.
  2. The treatment needed must match the treatments in the defined benefits on the PMB list.
  3. You must use Network Providers. This does not apply in life-threatening emergencies.

Additional information about Prescribed Minimum Benefits

 Appeal for out-of-hospital treatment

 Prescribed minimum benefit treatment guidelines

 Guide to submitting organ transplant claims

 Out-of- hospital management of a PMB

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 Option) depending on the healthcare service 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.
 
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