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Medical aid members today can choose to pay a lower contribution, in return for choosing to use specific doctors, hospitals and pharmacies.
While this benefit design was initially perceived by some as a benefit sacrifice, being able to save over 35% on their contributions has led to many members migrating to the flexibility of such options, where they can shape their cover to suit their pocket, as well as healthcare needs.
Two types of provider choice
When deciding whether a provider choice-type option is for you, you need to consider whether it would suit you to use:
1. any GP and pharmacy (for your chronic medicine), or a GP near you from a specific list of GPs in your area
2. any hospital, or a hospital near you from a specific list for planned hospitalisation
1. Choosing a GP and chronic provider
This one is relatively easy. Most of us have been using the same family doctor for years, so when joining a new medical aid or moving to a provider choice option, you can simply check their GP list to make sure that your doctor is on the list. If not, you will have to make the decision whether you would be comfortable changing to a doctor that is on the list, in exchange for a lower contribution.
Remember, a medical aid’s only income is from the contributions its members pay and from that they have to fund all claims and non-healthcare costs (the services needed to run the medical aid). Medical aids are non-profit organisations, and when they negotiate with service providers and enter into network agreements, they do so on their members’ behalf.
You can significantly save on your contribution by selecting State as your chronic provider. This means that if you are diagnosed with a chronic condition you would need to go to a State hospital to get your chronic prescription and medication. Remember, though, that you can change your medical aid option once a year, as your needs change.
2. Choosing a hospital
The main reason most members belong to a medical aid is so that they will be taken care of when involved in an emergency, for instance a car accident. The good news is that even if you are on a medical aid option where you have chosen to use a specific hospital in return for paying a lower contribution, that hospital choice does not apply in the case of emergencies – you can still use the nearest hospital in an emergency. Thus, the hospital choice would only impact you in terms of non-emergency hospital admissions, such as going for a planned procedure, for example to have your appendix removed.
How can your lifestyle help?
Medical aids are not allowed to reward members, or discriminate against them, based on their age, health and other lifestyle profile attributes. There are, however, ways in which members who adhere to prescribed treatment and who are active, can enjoy rewards ranging from increased GP visits to monthly payouts.
Members of some leading medical aid providers in South Africa have access to programmes administered outside of the scheme, whereby, for instance, if they go to gym regularly, they can earn up to R5 400 a year.
Depending on which option these members are on, they can also get additional in-hospital cover for specialists and extra GP visits. You can see how members who fall in this lifestyle category can reap great benefits! So when choosing a medical aid, ask yourself, “Are there opportunities to increase my benefits or savings without having to pay more?” But don’t forget to also ask, “How well established and sustainable is the scheme?” Look at its growth record over the past five years, as well as its solvency level, to make sure that the scheme you opt for can continue providing you with healthcare cover well into the future.
Consult an accredited financial adviser to help you make the right decisions for you and your family. Health is your greatest asset, yet healthcare cover often represents an area that isn’t sufficiently provided for or considered a grudge purchase. No one likes to pay for something that they don’t use, so this particularly rings true for people who are healthy. With the right advice and knowledge you can, however, make healthcare choices to suit your needs and your pocket and enjoy complete peace of mind.
