The Optical Benefit Medical Aid Guide

THE OPTICAL BENEFIT MEDICAL AID GUIDE

Many people don’t really understand how their optical benefits work, so we decided to write this blog to provide you with some useful information and tips. The information in this blog is based on my experience and knowledge of medical aids in general. These useful tips are meant to assist you. We haven’t included all medical aids, just the ones that we commonly see at our practice. I am in no way a medical aid expert 😊, just someone with experience in Optical Benefits with certain medical aids. The best way to use this Guide is to search for your medical aid and read the relevant information.

GENERAL:

1. Medical aids have Optical Benefits that pay either once a year or once in 2 years.

2. Each medical aid uses their own prescribed tariff. Optometrists and other service providers can charge this rate or a higher rate. If they charge a higher rate it’s probably a cash practice where you must pay cash and claim it back from the medical aid. The medical aid reimburses you less than what you paid, because they will pay you their tariff rate.

3. You will very likely find a list of the service providers that charge your medical aid tariffs on their website. If you choose these providers, you will save money.

DISCOVERY

PLANS WITH A SELF PAYMENT GAP AND ABOVE THRESHOLD LIMIT:

1. Twenty 20 Vision is a Preferred Provider with Discovery.

2. Log on to Discovery’s website and look for the Preferred Providers who charge Discovery Rates. You can reduce or eliminate the amount you pay in to Providers this way.

3. Certain Providers like ourselves, sign agreements with Discovery to give you a Preferred Discount. We’re a Preferred Optometry Provider so you get a 20% Discount on your Frame, Lenses & Extras.

4. You have a Savings, and all payments to Providers for out of hospital expenses are paid from this.

5. Each faculty like Optometry, Dentistry etc. have limits.

6. If you exceed these limits, you will have to pay in an excess, but you can claim back these excesses from Discovery if you have enough funds in the savings.

7. Do not use your medical aid savings to pay for any over the counter medication without a prescription, because these amounts are added to your self-payment gap. This increases the amount that you must pay in to reach your threshold.

8. When you reach your self-payment gap you can submit the medical receipts that you paid for in cash over the last 3 months, because anything prior to that would be regarded as stale.

9. For this reason, use your medical aid from the beginning of the year and only pay cash when you reach your self-payment gap.

10. When you’ve paid your self-payment gap, and you’ve reached your threshold, take your family for all necessary medical treatments to use this above threshold limit before the year ends. Discovery pays this benefit from their side, that is separate from your savings. This way, you will all be ready for the next year with a fresh savings to use.

PLANS WITH A SAVINGS ONLY:

1. This plan does not have an above threshold limit, so you can use it cautiously.

2. When your Savings is exhausted you will have to pay cash for all out of hospital expenses.

3. Log on to Discovery’s website and look for the Preferred Providers who charge Discovery Rates. You can reduce or cancel the amount you pay in to Providers this way.

4. Send us your details for more accurate benefits.

MEDICAL AIDS ADMINISTERED BY PPN:

SOME OR ALL OF THE PLANS OF THESE MEDICAL AIDS ARE ADMINISTERED BY PPN:

1. 2nd Benefit Warranty

2. Bestmed

3. Blackbird Getsavvi

4. Bonitas

5. Camaf

6. De Beers Benefit Society

7. Hosmed

8. Masibonisane

9. Medicall

10. Medihelp

11. Medimed

12. Moto Health

13. NBC

14. NHC

15. Opticred

16. PI Cover

17. Polmed

18. Private Medical Aid

19. Pula

20. Remedi

21. Sisonke Health Medical Scheme

22. Sizwe

23. Sizwe Copper

24. Thebemed

25.  Transmed

26. Unity Health

PPN USEFUL INFORMATION & TIPS:

1. Twenty 20 Vision is a Preferred Provider with PPN.

2. PPN is a capitation scheme. These medical aids above, outsource their optometry payments to PPN.

3. Some medical aids only outsource certain plans to PPN and not others.

4. Some Optometrists have agreed to PPN’s terms and accept those medical aids in our practices. We agree to charge the patients these rates and not more.

5. Look on the PPN website, for Optometrists that are Preferred Providers.

6. Most of these medical aids have a once in 2-year Optometry benefit that is a separate Optometry benefit & is independent of any Savings.

7. If you don’t use this benefit it just lies there. So be sure to renew your glasses every 2 years to maximise this.

8. PPN generally pays for the Test, Eye Lenses and have a limited amount for the Frame & Extras.

9. Some PPN medical aids like certain plans on Bankmed, pay for the Test & Lenses, but the Frame & Extras are deducted from the Savings.

10. The different medical schemes have rules that vary so this is just a broad description.

11. Send us your details for more accurate benefits.

MEDICAL AIDS ADMINISTERED BY ISOLESO:

SOME OR ALL OF THE PLANS OF THESE MEDICAL AIDS ARE ADMINISTERED BY PPN:

1. Discovery Keycare

2. Fedhealth

3. Sasolmed

4. Bankmed

5. Day 1 Health

6. Tiger Brands

7. Medshield

8. BP Medical Aid Society

ISOLESO USEFUL INFORMATION & TIPS:

1. Twenty 20 Vision is a Preferred Provider with Isoleso.

2. The above medical aids outsource their Optical payments of some or all their plans to Isoleso.

3. Optometrists can choose to be a Preferred Provider of Isoleso, where we accept their tariffs.

4. Isoleso generally pays for the Test, Frame & Lenses, sometimes as a package deal.

5. They do not generally pay for extras.

6. Send us your details for more accurate benefits.

UNIVERSAL ADMINISTERED MEDICAL AIDS:

SOME OR ALL OF THE PLANS OF THESE MEDICAL AIDS ARE ADMINISTERED BY UNIVERSAL:

1. AECI Medical Aid Society

2. BCIMA

3. CompCare

4. Gems

5. Makoti

6. Massmart Health Plan

7. Old Mutual Staff Medical Aid Fund (OMSMAF)

8. SAAB

9. Tiger Brands

10. Transmed

11. Umvuzo Health

UNIVERSAL USEFUL INFORMATION & TIPS:

1. Twenty 20 Vision is a Provider of Universal Health.

2. These medical aids generally pay for the Test, Frame and Lenses but not extras.

3. Gems has a very low benefit in my opinion and doesn’t cover Multifocal lenses in full. They pay partially for these lenses.

4. Gems also has a family limit.

5. It’s a 2-year benefit, so if you don’t use it, it just lies there.

6. If you’re on Gems, it’s a good idea to split your family members to have their glasses done in alternate years-Half the family this year and the other half next year to maximise this benefit.

7. They generally do not pay for extras, so the patient is liable for this.

8. Send us your details for more accurate benefits.

MEDICAL AIDS ADMINISTERED BY MEDSCHEME

SOME OR ALL OF THE PLANS OF THESE MEDICAL AIDS ARE ADMINISTERED BY MEDSCHEME:

1. AECI Medical Aid Society

2. Barloworld Medical Scheme

3. Bonitas

4. Fedhealth

5. Government Employees Medical Scheme (GEMS)

6. Horizon Medical Scheme

7. Hosmed Medical Scheme

8. MBMed Medical Aid Fund

9. Medshield

10. Namibia Health Plan

11. Nedgroup Medical Aid Scheme

12. Old Mutual Staff Medical Aid Fund

13. Parmed Medical Aid Scheme

14. SABC Medical Scheme

15. SAMWUME

16. Sasolmed

17. South African Police Service (POLMED)

MEDSCHEME USEFUL INFORMATION & TIPS:

1. Twenty 20 Vision is a Provider of Medscheme.

2. Medscheme medical aids vary with their benefits.

3. Send us your details and we will get your Optical benefits.

RESOLUTION HEALTH:

RESOLUTION HEALTH USEFUL INFORMATION & TIPS:

1. Twenty 20 Vision is a Provider of Resolution Health.

2. They have Optical Package deals that include the Frame, Lenses & Test.

3. They do not pay for Multifocals, only Single Visions & Bifocals.

4. They do not pay for Extras.

5. This is a 2-year benefit, so if you don’t renew your glasses in 2 years, the benefits will just lie there.

6. Send us your details for more accurate benefits.

OPTICLEAR

SOME OR ALL OF THE PLANS OF THESE MEDICAL AIDS ARE ADMINISTERED BY OPTICLEAR:

1. Keyhealth

2. Profmed

3. RFMCF

4. Imperialmed

5. Momentum Health

6. Ingwe

7. Wooltru

8. Wooltru Core

9. Bankmed

10. Gems

11. Carecross

12. MotoHealth Essential/ Custom

13. Horizon- Hospital Plus Network

14. Domesticare Plus

15. OCSA Care- Gold & Silver

16. Pick ‘n Pay Medical Scheme- Primary

OPTICLEAR USEFUL INFORMATION & TIPS:

1. Twenty 20 Vision is a Provider of Opticlear.

2. There are different benefits for the different medical aids.

3. Send us your details for more accurate benefits.

CONCLUSION:

Again, this is just a guideline. We hope that you’ve learnt one or two useful tips from this article. We will send you a more accurate report once you’ve given us your details and we call the medical aid directly.