09 December 2015

Consider this when choosing a medical scheme

We all shop around for good value, but how much thought do we give to choosing a medical scheme that truly suits our needs?

Your medical scheme is an important investment in your and your loved ones’ health and wellbeing, and it is therefore vital to ensure that your scheme is not only offering you affordable cover, but benefit richness as well,” says Dr Jacques Snyman, Acting CEO of Agility Global Health Solutions [Africa] (Agility Africa), a medical scheme administrator and managed care provider to the South African healthcare market.

When considering a healthcare partner, Dr Snyman recommends that individuals and families alike bear the following key factors in mind:

Understand what you are paying for

There are 83 medical schemes in South Africa. Their benefits vary tremendously, as do their costs. Choosing the best one for you and your loved ones can therefore be a daunting task. It is worth seeking advice from an objective healthcare intermediary or broker who can offer you a global view of what is on offer in the industry.

However, always make sure that your broker is accredited with the Council for Medical Schemes.

Do your homework and read the literature

Read the scheme literature carefully, particularly the fine print. This will make sure you are not left red-faced and out of pocket for costs that are not covered by your option. “Many individuals focus on affordability and only scan their benefits quickly.  Remember, you need to make sure you have cover for your specific needs, not just to suit your pocket,” says Dr Snyman.

Prescribed minimum benefits demystified

By law, medical schemes must cover the treatment of 270 medical conditions, known as prescribed minimum benefits (PMBs), which include 25 chronic diseases defined in the Chronic Disease List, and all emergency (life threatening) conditions.

“Take time to understand the PMBs as this will give you a clear understanding of what falls within their ambit, and what does not. PMBs are not a blank cheque. You are not automatically covered in full if you choose to use a provider for your PMB treatment that is not contracted to your scheme. Only in the case of an emergency can you use any provider, and then only until you can be moved to a scheme preferred provider,” Dr Snyman notes.

The costs

With medical schemes you get what you pay for. Those who are price-focused should ensure that their cover meets their minimum expectations every year.

“For example, there are some major differences in the cover provided by medical schemes and insurance products respectively,” says Dr Snyman. “Again, in each case you should read the small print and make sure that you are aware of all exclusions and limitations. Carefully consider what real value the product offers. It is perfectly acceptable to look for affordability when it comes to medical cover, but at all costs avoid a situation in which you find you have inadequate cover when you or a member of your family develops a serious health problem or needs access to acute hospital care.”

Administration costs

Find out what your scheme’s administration costs are. Medical schemes are either self-administered or run by a third party, such as Agility Africa.

Make sure the scheme you choose is well administered. If a scheme’s non-healthcare costs are high, they are spending less on your benefits.

Average increases

Enquire what the scheme’s average fee increases were over the past few years. Look at rand values, not just percentages, and be sure to check if there were any benefit cuts. For example, some medical schemes may cut back on benefits while posting fairly low annual increases, putting you at risk of having fewer benefits in the long run.  

Beware the exclusion periods

When you join a new medical scheme you may be faced with waiting periods for certain treatments. Also, if you have a pre-existing medical condition it is well within the rights of your medical scheme to withhold cover for that particular condition for a set period.

It is imperative that you disclose any pre-existing medical conditions that you may have when joining a new medical scheme. If you try to claim for a condition you failed to disclose, the scheme can refuse to cover that particular illness and may even opt to cancel your membership. 

Medical savings accounts

In terms of the Medical Schemes Act, up to 25% of the members’ premiums can be set aside and put into savings accounts. The medical savings account (MSA) affords members a form of credit and ensures that funds are not used to cross-subsidise other members.

The fact that cross-subsidisation is virtually eliminated holds a certain appeal to healthy members. On the other hand, members often feel aggrieved when the savings account is depleted and they are forced to dip into their own pockets to fund their medical expenses.

If a medical scheme member accumulates a credit balance in their MSA, they cannot draw the cash. This is only possible upon termination of membership of a medical scheme and on the proviso that another medical scheme with an MSA option is not joined, says Dr Snyman.

“My advice to healthcare consumers would be to weigh up the pros and cons of a medical savings account versus the security of allocated benefits in a traditional option,” says Dr Snyman.

“With the healthcare market evolving every year, it is important to relook at your healthcare option in relation to your needs at the end of each year and be sure that the cover you are getting is the cover you need,” Dr Snyman concludes. 

Read more: 

The best medical aid in SA  

Clear separation between medical insurance ans medical schemes  

What to consider when changing your medical scheme


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