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Updated 22 January 2016

Are South Africans baffled by medical scheme benefits?

The medical scheme industry is full of jargon and benefit structures that often leave the man on the street confused and frustrated when it comes to understanding and accessing their benefits.

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Medical schemes have in recent times attempted to simplify terminology to make it more understandable, but are they doing enough to ensure members know what they are paying for? 

A recent survey among Resolution Health Medical Scheme (Resolution Health) members revealed that 87% of respondents felt that they generally understood the benefits they were entitled to on their specific benefit option, while 13% said that they found their benefits more than a little confusing.

This is a worrying statistic says Mark Arnold, Principal Officer of Resolution Health, as it means that a large number of members are not receiving advice from a healthcare broker when it comes to choosing their healthcare option, and may lead to members not having the level of cover they need.

Read: Clear separation between medical insurance and medical schemes

The survey showed that just over a fifth of respondents do not review their healthcare needs annually to ensure that they have adequate cover on their specific benefit option.

“Many of the complaints consumers have regarding the healthcare industry as a whole relate to either a misunderstanding of benefits or members’ healthcare needs increasing without them reviewing their option annually,” says Arnold. “I cannot emphasise enough the importance of an annual review of cover, as benefits on options and healthcare needs change each year. 

Making sure you still have all the cover you need is essential.”Just over a quarter of respondents said that they did not understand the difference between savings-based medical scheme options and traditional options, while exactly a quarter did not know what a Prescribed Minimum Benefit (PMB) is.

“Traditional healthcare plans have allocated fixed benefit amounts for various treatments such as dental, optometry; day-to-day etc. whereas a savings based option provides funds which you as the member decide where to spend,” explains Arnold.“PMBs are a basic tenet of private medical insurance, as these are the set of health services that medical scheme members are entitled to by law, irrespective of which benefit option they are on,” says Arnold.  


Read: What will happen if PMBs are charged at medical aid rates?

PMBs are defined under the Medical Schemes Act, which states that medical schemes have to cover diagnoses and treatment of emergency medical conditions, 270 medical conditions and 25 chronic medical conditions.  “But PMBs are not a blank cheque and there are certain limitations that members need to make themselves aware of,” he adds.

The survey also found that 54% of respondents chose their benefit option based on price, while the remaining 46% chose according to the benefits needed by the household. Those choosing on the basis of price were 30% less likely to conduct an annual review of their healthcare cover than those who chose on the basis of benefits. 

Nearly a third of respondents indicated that they find limits and sub-limits to be the most confusing aspect of their medical insurance. Seventeen percent identified medication lists and benefits as the most difficult aspect to understand, and another 17% found co-payments the most confusing.

However, a further 15% found all three of these aspects confusing. Just over a tenth of respondents found savings management most difficult to comprehend, while 10% said PMBs were most confusing to them. 

Read: Don't let medical aid schemes bamboozle you

“It is troubling to note that members struggle to understand such a wide variety of aspects of their medical scheme cover,” says Arnold. “This is why it is essential to consult with an accredited broker when choosing your cover so that they can give you clarity on all aspects of your benefits.

This will go a long way to eliminate confusion, frustration and dissatisfaction in the long run,” explains Arnold.“In order to help our members get the best out of their benefit option, we need to empower them with knowledge.

This survey showed that Resolution Health members do generally have a good grasp of the concepts, but also indicates to us which areas require further attention,” Arnold said. “We will incorporate these insights as part of our ongoing efforts to help members understand their benefits, and ultimately enjoy the cover they need at every life stage,” he concluded.

Read more:

Medical Schemes Act: proposed amendments to PMBs

New amendments to medical scheme act should keep medical inflation in check

SA medical schemes in favour of improving clinical quality healthcare

Article image: Money jar from iStock

Infographic supplied

 
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