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Understanding my medical scheme

THE purpose of a medical scheme is to ensure that you are able to pay for treatment received from either a General Practitioner (GP) or any other service provider while in or out of hospital. THE purpose of a medical scheme is to ensure that you are able to pay for treatment received from either a General Practitioner (GP) or any other service provider while in or out of hospital.

THE purpose of a medical scheme is to ensure that you are able to pay for treatment received from either a General Practitioner (GP) or any other service provider while in or out of hospital.

Manage All classifies medical scheme benefit options into 6 levels of cover which are as follows:

LIMS options

- usually the Capitation or Network options offered by Medical schemes, where you need to make use of specific hospitals and contracted general practitioner (GP), with limited benefits for chronic and acute medicine, dentistry and optical benefits. 

Hospital plans

- offered by medical schemes, is exactly what the name indicates; a plan covering only hospital benefits. It will cover general hospital benefits such as accidents, heart attacks and any other procedure or services which need to be performed in a hospital. Hospital plans offered by a medical scheme will not cover any “out-of-hospital” benefits such as consultations, acute medication, dentistry and optical but will cover chronic medication. 

Basic options

- are designed to cover the basic needs. The basic options are limited, offering in and out-of-hospital benefits. It is designed for young and healthy people, with low medical expenditure, such as consultations, chronic and acute medication or dentistry. 

Standard options

- are those options on which most people should be with a healthy family and little or no chronic conditions. 

These options are designed for people who are healthy, and take care of themselves by having a general check-up every year and visiting a dentist at least once a year. 

Executive options

- are designed for people who need extensive cover. It covers up to 62 chronic conditions, which include the 27 Prescribed Minimum Benefits. The larger family will opt for this level of cover. 

It is usually the family with two of more children and the adults are above the age of 45 years, using moderate chronic medication and visiting a healthcare provider on a regular basis.

Ultimate options

- are the flagships of medical schemes and offer the best benefits on all levels of cover. Ultimate options are rich in benefits with generous limits. They are designed for the person who doesn’t want to manage his. or her medical scheme but rather pay a high premium to cover most of their needs. These options normally pay up to 300% of the medical scheme tariff, with little or no co-payments for procedures or services.

It is by no means an easy task and can be quite daunting at the best of times. Once you have assessed your and your family’s medical needs, you should then call the services of a specialist medical scheme consultant such as Manage All. They will assist you in making the right decision. 

Manage All (Pty) Ltd is an authorized financial services provider (FSP:14445) a national specialised Medical Scheme consultancy company, specialising only in Medical Scheme and related products such as Gap Cover and Co-payment waivers.

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