Explaining to your clients what exactly they get with their benefits can be a tricky business. We’re all used to describing terms with the accepted industry jargon, but for a layman, it can be downright confusing.
To help your clients better understand what it is they get and don’t get with their cover, we’ve put together an easy to understand summary of each term.
The PMB list – Simply put, this is the list of 271 conditions that the Council for Medical Schemes has designated that all medical schemes should pay for members. The list consists of 25 chronic conditions and a list of emergency medical conditions and treatments. Treatment of these conditions cannot be refused on reasonable grounds. The full list of PMBs can be found at https://www.medicalschemes.com/medical_schemes_pmb/
Day-to-day benefits – These are the benefits that you get for out-of-hospital medical procedures. This includes items like doctors’ visits, optometry, dentistry, and medicine among others. The level of benefits you get is determined by your medical scheme option.
Self-payment gap – On new generation cover options. Once your day-to-day benefits are exhausted, you enter the self-payment gap, whereby you pay for certain medical expenses out of your own pocket, as per your option. Depending on your option, you will pay for a certain number of these treatments until you enter your above-the-threshold benefit, which too has a limit.
Above-the-Threshold benefits – Once you have entered the Above-the-Threshold benefit, certain out-of-hospital treatments are once again paid for by your medical aid, up to a set limit as per your option. Always check to see what your self-payment gap is when choosing your option.
Sub-limits – A sub-limit is a limit on certain procedures within your overall cover limit. This can be on anything from internal prosthesis to scans.
Formularies – The list of medications that your medical scheme will pay for. If you choose a medication that is not on the list, your medical scheme may not pay for all, if any of the cost of the medication.
So, the next time your clients want to know what they get and what the jargon means, simply refer to this handy guide.