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Medical aid jargon explained in plain English

PMB. DSP. CDL. LJP. MSA.

If you have ever listened to someone in the medical aid industry and wondered whether they were discussing healthcare or playing a very complicated game of Scrabble, you are not alone.

Medical aid can come with its own language.

The problem is that these little acronyms can have a very big impact on your wallet and your healthcare.

So, before you smile politely and pretend you know exactly what a DSP is, here is the Universal Cover guide to some of the medical aid terms you actually need to understand.

PMB: Prescribed Minimum Benefit

Plain English:

Healthcare your medical scheme is legally required to cover, subject to the rules that apply.

Prescribed Minimum Benefits — or PMBs — are minimum healthcare benefits that registered medical schemes must provide.

They include emergency medical conditions, specified medical conditions contained in Diagnosis and Treatment Pairs, and chronic conditions on the Chronic Disease List. The Council for Medical Schemes currently lists 26 chronic conditions as part of the PMB framework.

Think of it like this:

A PMB is not a free pass for absolutely any treatment from any doctor at any price.

Your scheme may require you to:

• Use a particular healthcare provider.
• Follow a treatment protocol.
• Use medicines on its formulary.
• Register your chronic condition.

Follow the rules and PMB treatment should generally be funded according to the legislation and your scheme’s applicable arrangements.

Ignore those rules voluntarily and you could find yourself paying part of the account.

Which brings us to…

DSP: Designated Service Provider

Plain English:

The doctor, hospital, pharmacy or other provider your medical scheme wants you to use for certain healthcare services.

A DSP can be a doctor, pharmacy, hospital or other healthcare provider selected by the medical scheme for the diagnosis, treatment or care of PMB conditions.

In even plainer English:

Your medical aid may effectively be saying:

“We’ll cover this according to the PMB rules, but please use one of these providers.”

If you voluntarily go somewhere else, you may have to pay a co-payment or the difference in cost.

There are exceptions. For example, different rules can apply in emergencies or where the DSP is not reasonably accessible or able to provide the required service.

Ask your adviser:

“Who are my DSPs, and are they conveniently located for me?”

That question can save you money later.

Co-payment

Plain English:

The part of the healthcare bill you have to pay yourself.

Imagine your procedure costs R10,000.

Your medical scheme pays R8,000.

The remaining R2,000?

That could be your problem.

Co-payments can arise for different reasons depending on the option, including using certain non-network providers or choosing treatment or medicine outside specified arrangements. The exact rules must be checked against your particular scheme and option.

Important question:

Don’t simply ask:

“Is this procedure covered?”

Ask:

“Is it covered in full, and are there any co-payments?”

Those are two very different questions.

Network

Plain English:

A group of healthcare providers your medical aid has arranged for you to use.

This might include:

• Hospitals
• GPs
• Specialists
• Pharmacies
• Dentists
• Optometrists

Some medical aid options are cheaper because they require you to use specific networks.

That can be an excellent way to reduce your monthly contribution — if the network works for you.

A fantastic hospital network 300 km away is not particularly useful when your appendix has other plans.

Before choosing an option, check which hospitals and providers are actually available near your home and workplace.

Formulary

Plain English:

Your medical scheme’s approved medicine list.

A formulary is a list of medicines the scheme has approved for treating particular conditions.

Your doctor may prescribe Medicine A.

Your medical scheme’s formulary may prefer Medicine B.

If you choose medicine outside the formulary when an appropriate formulary medicine is available, you may have to pay some or all of the difference, depending on the scheme rules. There are protections where the formulary medicine is ineffective, causes adverse effects or is otherwise clinically inappropriate.

Ask:

“Is my current medicine on the formulary for 2027?”

Especially if you use chronic medication.

CDL: Chronic Disease List

Plain English:

A list of chronic conditions included within the PMB framework.

These include conditions such as hypertension, diabetes, epilepsy and several others.

But having a condition on the list does not necessarily mean you can simply visit any doctor, use any medicine and send the bill to your scheme.

Registration, treatment protocols, DSPs and formularies may still apply.

Translation:

Covered does not mean “anything goes”.

Find out how your scheme expects you to access the benefit.

Waiting period

Plain English:

You have joined the medical aid, you are paying for it — but certain benefits may not be available to you yet.

Yes, that can happen.

There are two main types you are likely to hear about.

General waiting period

A general waiting period can be up to three months in circumstances permitted by the Medical Schemes Act.

During the waiting period you continue paying your contribution, but you may not be able to claim certain benefits. The rules around PMBs depend on your previous medical scheme membership and the circumstances under which the waiting period was imposed.

Condition-specific waiting period

This can be up to 12 months for a pre-existing medical condition in qualifying circumstances.

For example, if you already have a particular condition when joining, the scheme may be permitted to exclude claims related to that condition for the applicable waiting period.

This is why you should never assume:

“I’m joining a new medical aid next month, so everything will immediately be covered.”

Ask first.

LJP: Late Joiner Penalty

Plain English:

An extra amount that may be added to your medical aid contribution if you join later in life without sufficient previous medical scheme cover.

This one deserves attention.

A late joiner generally refers to someone aged 35 or older who meets the relevant criteria under the Medical Schemes Act and regulations. Previous qualifying medical scheme membership — known as creditable coverage — is taken into account when determining whether and how a penalty applies.

Depending on the calculation, the maximum penalty bands can range from 5% to 75% of the relevant contribution portion.

And this is not necessarily a once-off joining fee.

It can affect your ongoing contribution.

Important:

Keep proof of your previous medical scheme membership.

Those old membership certificates you nearly deleted from your email may suddenly become very valuable.

MSA: Medical Savings Account

Plain English:

Money allocated to help pay for certain day-to-day healthcare expenses.

Depending on your option, part of your medical scheme contribution may be allocated to a medical savings account.

You may then use it for qualifying expenses such as GP consultations, medicine or other day-to-day claims, according to your scheme’s rules.

The important thing to understand is:

Savings are still your healthcare money.

If you spend your available savings quickly, you may have to fund further day-to-day expenses yourself unless your option provides additional cover.

Also important: PMB costs may not simply be taken from your medical savings account where the scheme is required to fund them as PMBs.

Pre-authorisation

Plain English:

Ask your medical aid for approval before certain treatment takes place.

Planning a hospital admission?

A procedure?

A scan?

Don’t assume that handing over your medical aid card at reception means everything is sorted.

Some services require pre-authorisation.

And remember:

Authorised does not always mean paid in full.

Ask:

• Is the hospital in the network?
• Is the doctor covered at the applicable rate?
• Is there a co-payment?
• Are there benefit limits?
• Does the procedure itself have specific rules?

That five-minute conversation beforehand can prevent an unpleasant surprise afterwards.

Scheme rate or medical scheme tariff

Plain English:

The amount your medical aid has agreed or determined it will pay for a particular healthcare service.

Here is where confusion often starts.

Your specialist might charge R2,000.

Your scheme might reimburse R1,200 according to the applicable rules and tariff.

That does not necessarily mean somebody made a mistake.

It could mean the healthcare provider charged more than the amount your option covers.

Ask:

“Does my medical aid pay this provider in full, or could I have a shortfall?”

Benefit limit

Plain English:

There is a ceiling.

Your brochure might say:

“Optometry benefit: R3,000.”

That does not mean unlimited glasses, eye tests and contact lenses.

It means the scheme will pay according to the applicable rules up to the stated limit.

Once you reach that limit, further qualifying expenses may become your responsibility.

Exclusion

Plain English:

Something your option does not cover.

Medical schemes are subject to strict legislation and cannot simply exclude PMB conditions where PMB entitlement applies.

However, benefit options can still contain exclusions and limitations for services outside the PMB framework.

Read them.

The section called “Exclusions” may not be the most exciting part of the brochure.

It may, however, be one of the most important.

Emergency medical condition

Plain English:

A sudden, unexpected medical situation where delaying treatment could cause serious harm.

An emergency medical condition has a specific meaning under the PMB regulations. Broadly, it involves a sudden and unexpected condition requiring immediate medical or surgical treatment, where failure to treat could lead to serious impairment, lasting damage or death.

So no, simply arriving at the emergency department at 2am does not automatically make every condition a PMB emergency.

The clinical circumstances matter.

The most dangerous medical aid phrase?

“I thought it was covered.”

Many unpleasant medical aid surprises start with those five words.

I thought the hospital was covered.

I thought my medicine was covered.

I thought there was no waiting period.

I thought the specialist would be paid in full.

I thought PMB meant everything was free.

Medical aid terminology may sound unnecessarily complicated, but understanding a few key terms can have a significant impact on what you ultimately pay.

You don’t need to become a medical aid expert

That is what your adviser is there for.

A good medical aid adviser should be able to take:

PMB + DSP + CDL + MSA + LJP

and translate it into:

“Here is what this actually means for you and your family.”

Before joining, switching, upgrading or downgrading your medical aid, ask your adviser to explain:

• What you are covered for.
• Which hospitals you can use.
• Which doctors and pharmacies you should use.
• What you might have to pay yourself.
• Whether waiting periods could apply.
• Whether a Late Joiner Penalty could apply.
• How your chronic medicines will be covered.
• Which important limits or exclusions you need to know about.

If you don’t understand the answer, ask again.

Medical aid is complicated enough. The explanation shouldn’t be.

Speak to Universal Cover

At Universal Cover, our advisers help translate medical aid terminology into language that makes sense.

Because you shouldn’t need a dictionary to understand your healthcare cover.

No jargon. No alphabet soup. Just help understanding what your medical aid means for you.