1. Which scheme offers the best value-for-money
(i.e. the extent of medical cover in relation to premiums charged). It is important to compare the benefits of a specific option at a specific premium level, for example:

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• At what rate are specialists reimbursed in hospital (100% / 200% or 300% of standard rates)
• What sublimits and restrictions are in place for the benefits (e.g. overall annual limit, submit per prosthesis etc)
• Are the benefits only available at certain facilities (e.g. state hospitals / private network hospital) or at a certain provider (e.g. specialist network)
• Are there co-payments applicable?
• What day-to-day benefits are covered (e.g. savings, threshold, traditional, capitated provider).
• Are there specific formularies (e.g. generic chronic formulary)

2. Does the scheme offer simple and sufficiently differentiated options to cater for your healthcare needs?

• Different levels of hospital cover on the various options
• Choice of Chronic, hospital and day-to-day providers
• Choice of type of day-to-day cover (capitation, new generation and traditional
• Varied contribution levels to cater for different affordability levels
• Given the above, there should not be too many different options or choices as this would make it difficult to make the right choice for you and your family.

3. What is the financial stability of the scheme?

• What is the current (and expected future) solvency levels of the scheme? The statutory minimum solvency level for medical schemes is 25%. However, there are schemes that are financially stable with solvency levels below that mark. Focus on whether the scheme has an age profile that is reducing over time and whether the solvency level is expected to increase in the future.
• Did the scheme show a positive financial result for the previous financial years? Some schemes are currently funding lower contributions with reserves. Even thought this could be an appropriate strategy in the short term, it is not sustainable in the longer term.
• What is the Global Credit Rating (GCR) of the Scheme? GCR is an independent rating agency that assesses the claims paying ability of most major medical schemes in the country.

4. How has the scheme’s membership profile changed over time?

• In the current community rated environment, before the implementation of the Risk Equalisation Fund, it is fundamental for a scheme to manage the age profile of its membership base.
• Has the scheme’s age profile remained consistent over time, or ideally reduced over time? How does the age profile compare to the average age of the industry (this is approximately 43 years for principal members)
• Has the scheme grown in membership the past few years? It is important for a scheme to grow sufficiently with the right members to mitigate the ageing of the current population. As a rough guide, for every year a scheme ages, the claims costs increase by 2%. This would affect your future contributions directly.

5. Ask your healthcare provider and friends about their service experiences with the scheme.

• The administrator of the scheme is responsible for the service experience. The past experience may change if the scheme changes administrators and / or amalgamates with another scheme.

6. Is the philosophy of the scheme focused on improving wellness and maintaining the optimal health of its members?

• A key focus of a medical scheme should be to provide the optimal healthcare benefits to members, given the funds available to them.
• It should support the consumer driven healthcare philosophy by empowering its members to make smart healthcare decisions. This includes promoting and encouraging early detection and preventative care.

7. Can the scheme comprehensively provide for other wellness needs:

• E.g. a lifestyle programme to support (and reward) a balanced lifestyle
• Flexibility outside of the scheme to allow for (e.g.) additional day-to-day needs

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