A ruling by the Council for Medical Schemes (CMS) opens up the potential for members to demand that their medical aid pays for any drug or medical care deemed necessary by a doctor to treat any disease that falls under PMB basket of care.
Image source: Getty/Gallo
This is after a glaucoma patient took on Discovery Health Medical Scheme because it refused to pay for a medicated device called a Xen stent to lower eye pressure as recommended by a specialist, even though it was willing to pay twice as much as the device costs for treatment it recognises. The medical scheme denied the claim on the basis that clinical evidence around the implant was weak. It also said it was legally entitled to refuse payment for the device because it was not available in state hospitals.
The ruling could have a huge impact for cancer patients, where, in the past medical aids have refused to pay for drugs outside of their formulary. Last year, Dr Sipho Bvuma asked his medical scheme Gems, to pay for a special drug treatment called Keytruda for his stage 4 brains cancer. At first, Gems refused because the medication is not registered in South Africa as a treatment option for the specific type of cancer. It was only after Bvuma instituted court proceedings that the scheme changed its mind.
Medical aid may feel like a grudge purchase until you find yourself faced with a health issue, and unexpected and expensive medical or hospital costs. Unfortunately, healthcare inflation continues to outpace general inflation by about 5%. So, while consumers continue to struggle to make ends meet, medical aids need to explore ways to contain costs without compromising the level of healthcare offered to members.
Lee Callakoppen, Principal Officer of Bonitas Medical Fund.
We cannot argue that high costs are beyond our control and expect our members to just take it on the chin. We need to continue to be proactive in finding new and innovative solutions to contain costs while still offering value and a high level of care. More active disciplined management will be required under the current economic climate in 2020.
We believe there are areas of inefficiencies. As stakeholders in the system, we need to address this constructively in order to change the healthcare landscape. This involves empowering both members and providers as was clearly set out in the recent Health Market Inquiry (HMI) Report. Some recommendations in the report, specifically the regulatory reform, will go a long way to transforming the current landscape and making healthcare more affordable.
Bonitas, like all medical schemes in South Africa, is a non-profit trust, registered with the Council for Medical Schemes (CMS). The schemes are owned by their members, governed by a board of trustees and all surpluses are invested back into the scheme on behalf of members.
Growth and retention of membership are imperative for any fund, so it is up to the scheme to find innovative ways of adding value and keeping costs as low as is sustainably possible. In addition, as the age of membership increases, schemes need to attract younger, healthier members to balance the risk pool. Bonitas has expanded its product offering to meet the needs of younger individuals – which has contributed towards its growth.
We feel confident we are addressing the issue of affordability and having a wider appeal thanks to our product lineup. Testimony to this is that we saw a growth of 50,300 members in 2019 (3.2%) despite uncertainty around NHI, a poor economy, low salary increases (around 5%) and an average rise of 10% in medical aid contributions.
Medical aid plans can be confusing which is why it’s important to compare the various options and benefits to ensure you find a medical aid that works for you and your family’s health and that is within your budget…
We create partnerships with defined networks of hospitals and specialist service providers who help us limit utilisation and costs, without compromising members’ access to quality healthcare.
Managed care: There is an increased prevalence of lifestyle diseases such as diabetes, hypertension and cardiovascular disease as well as HIV/Aids, cancer, chronic medicine management, back and neck pain, hip and knee replacements and mental illness. For this reason, we have a number of managed care programmes aimed at predicting and preventing conditions before they become chronic and managing them in the most clinically appropriate way.
Fraud, waste and abuse: The growing incidence of fraud, wasteful expenditure and abuse of member’s benefits is another factor that impacts the cost of medical aid. In partnership with our administrator, we have been meticulous in our zero-tolerance response to these unethical practices, deploying forensic software and other resources to identify and address these criminal activities. We involve our doctors and specialist networks in seeking solutions that service the interests of our members Over the past three years this has saved the scheme and its members over R174m. Significantly over R153m of this is attributable to a positive change in the claiming behaviour of wrongdoers after they were investigated and sanctioned.
1. How members can curtail costs
Use Designated Service Provider (DSPs) network for hospitals.
By using networks on certain plans we are able to get better rates for members without compromising quality of care. This, in turn, enables members to pay a lower monthly contribution in exchange for using DSPs.
Additional benefits
Check which benefits are included on your option that can potentially save significant day-to-day expenses. Such as preventative care benefits, ranging from basic screenings (blood pressure, cholesterol, blood sugar and body mass index measurements) through to mammograms, pap smears, prostate testing.
Minding the Gap
If your option applies co-payments for defined procedures or covers you for only 100% of the medical scheme’s rate (and not the rate actually charged by the doctor), it is worth your while to investigate gap cover. This is a separate insurance policy you can take out to cover you and your family, for the difference between the medical scheme rate and what the provider has charged you (up to a maximum defined level).2. Chronic and intermittent medicines
Almost all options on all medical schemes apply a medicine formulary. This is a list of drugs which the scheme will cover in full. If you use medication that is not on the formulary, you will be liable for the difference. Discuss the formulary medication with your doctor to see if this is appropriate for you.
The schemes can also specify that you obtain your medication from DSP pharmacies. If there are none close to you, most schemes also designate a courier pharmacy to deliver the medication to you at a preferred address.
Ask your pharmacists for generic medicine. 100 million prescriptions are filled for generic medicines in South Africa per annum. This equates to 78% of the generalised market opting for a far more cost-effective drug where the pharmacological effects are exactly the same as those of their brand-name counterparts
Everything implemented by Bonitas, designed to curtail spiralling health costs, is on behalf of our members. After all, the Fund belongs to the members, so any interventions are to protect their interests within the ambit of the Medical Schemes Act.
Medical aid is one of the biggest cost centres on many family budgets, then there is the tricky business of understanding what is covered and what is not. It’s therefore important to choose one that is right for you and your health needs and will potentially not leave you financially ruined?
Image source: Getty/Gallo
Tip 1: Find a medical aid you can trust
All official medical schemes should be registered with the Council for Medical Schemes (CMS). If you are worried that a certain provider is not legitimate, you can go to the CMS website to verify their validity.
No one knows your needs better than you. It’s up to you to do your own research. Luckily, schemes provide smart internet capabilities which can compare a wealth of information of their products in the market. Easy to access member feedback portals also provide first-hand accounts on how schemes treat their members.
You can also speak to a broker. With so many schemes out there, it can feel impossible to properly weigh up the pros and cons of them all. A reputable broker has knowledge of the different schemes and can provide a personalised answer based on your needs.
Tip 2: Know the difference between a medical scheme and health insurance
Confusion tends to set in when deliberating the difference between medical schemes and health insurance. In the end it comes down to cost versus benefits and remember cheap usually means fewer benefits.
If you need peace of mind or more generous care, then you definitely need a medical scheme. If you are looking for affordable basic cover under R500 a month, then you can look at health insurance. However health insurance products typically pay a larger proportion of your premium to marketing, distribution and administration costs.
When belonging to a scheme, remember you effectively are a shareholder of the business and with any remaining profit or “surplus” at the end of the year is then saved for future years claims. Medical schemes even the lowest cover sometimes refer to as “hospital plans” must offer what is known as Prescribed Minimum Benefits. According to CMS, these are benefits that ensure that all medical scheme members – regardless of the provider and the benefit option – must have access to certain minimum health services.
Prescribed Minimum Benefits are defined in the Medical Schemes Act, and all medical schemes have to cover the costs related to the diagnosis, treatment and care of:
Any emergency medical condition
A limited set of 270 medical conditions (defined in the Diagnosis Treatment Pairs);
25 chronic conditions (defined in the Chronic Disease List)
Medical insurance sits on the other end of the value scale, paying a set amount for your stay in hospital. This cost is often not nearly enough considering the high costs of medical care in a general, high care or intensive care unit.
Tip 3: Understand the limits of a hospital plan
To cut costs, many people choose to downgrade their medical aid cover to a hospital plan. If you’re with a CMS accredited medical scheme, then you can rest assured that even the lowest level hospital plan should comply with the above mentioned Prescribed Minimum Benefits. You also need to be aware that every visit to the hospital emergency rooms does not count as hospitalisation. Even if you think it was a medical emergency, there is a difference between getting treated as an out-patient and being admitted and so some visits to emergency rooms may in fact come from your day-to-day or savings benefits unless you are admitted.
It is critical to understand that that many schemes have a limit on their hospital cover. They will require you to attend only certain hospitals and may have a hospital limit on what is covered depending on your scheme and plan.
Tip 4: When first becoming a member of a scheme, prepare to wait
If you are looking to sign up for medical aid, you can almost certainly expect a waiting period. There are two types of waiting periods or underwriting conditions.
The first is the general waiting period. If you are healthy, under 35 and haven’t been on a medical scheme before, you will generally only have to wait three months before full cover takes effect.
The second is called condition specific waiting period. This applies if you have a pre-existing condition or injury prior to joining the scheme. In these cases, the standard practice is that schemes apply a 12-month condition-specific waiting period before you can access benefits relating to these pre-existing conditions, which is standard practice.
It is best to disclose your pre-existing conditions as three or 12 months is not a long time to wait. This is a contractual relationship at the end of the day and by not disclosing your condition after signing the contract, the scheme has full rights to terminate you from the scheme and refuse cover.
An additional matter to be aware of is if you are delaying becoming a member of a medical scheme, you may be required to pay late joiner penalties for the rest of your life. This is applied by all schemes to encourage younger members to join early rather when its too late. These penalties will follow you regardless if you move medical schemes at a later stage and can cost you up to 50% more than the scheme premium. This is depending on your age.
Tip 5: Be careful of loyalty frills
It’s easy to get caught up in the excitement of loyalty benefits. The reality is that promoting healthy behaviour improves your lifestyle but things such as discounted flights or free movie tickets won’t help you when you have a car accident and are taken to the ICU. Too many people mistake frills and loyalty-based products as core healthcare benefits they are buying only to discover that they don’t have the proper cover they need when the time comes.
Don’t be fooled by big brands that market frills because you will literally pay the price when it is too late. Ultimately, it’s important to understand the pros and cons of choosing a medical aid especially based on your needs and affordability.
Accessible and quality healthcare is a pillar of sustainable development and global security. The principle behind this is that no one should fall into poverty because they get sick and need healthcare. South Africa’s response to the global call for universal healthcare is the National Health Insurance (NHI) bill, which aims to provide everyone with access to appropriate, efficient and quality health services.
Dr Brian Ruff, co-founder of PPO Serve
“The Health Market Inquiry has spelt out the failure of the private sector to make affordable quality healthcare available to more people. To move towards universal health coverage, holistic care delivered by a multidisciplinary team is required,” says Dr Brian Ruff, co-founder of PPO Serve.
Access to quality healthcare forms the basis for the realisation of a wide variety of socioeconomic rights. The purchaser role put forward by the NHI will ensure the efficient use of resources to benefit the country’s entire health system. “The model introduces a single fund that will also support the purchasing of medical services for the country,” he says.
In contrast to the current model, in which schemes attempt to manage care and spend through restricted benefits and pre-authorisation, the NHI fund will be responsible for the lives of 57-million South Africans. “Under it, providers – whether public, private, or not for profit – will compete for local contracts based on how well they deliver value. This includes primary healthcare and hospital services,” says Ruff.
Value-based care
The goal of universal health coverage is to provide full comprehensive care to all citizens and legal residents of a country. “By pooling funds, the NHI has the ability to provide access to quality and affordable health services for all South Africans based on their healthcare needs and irrespective of their socioeconomic status. There are many countries, with less resources who provide quality healthcare care for everybody,” he says.
To work effectively, the NHI needs to appoint a competent team to design template strategic contracts that are robust and fair. “These value-based care contracts must use payment models that support the use of all available resources, that reflect population needs and that reward good outcomes. This means the model needs case mix tools – data which shows that patients are treated at the right level of care relative to their illness – to be available at every level of the system.”
Population medicine models demonstrate their value by improved measures of both the quality of healthcare delivered, as well as a reduction in spend. “The strength of this team-based and community level model is in managing complex medical conditions as well as the direct impact of social, psychological and financial circumstances on patients’ illnesses and treatment,” says Ruff.
While the South African Medical Association (Sama) is in support of the principles of universal health coverage and quality care for all, it has not been able to support the 2019 National Health Insurance (NHI) Bill in its current format, the organisation said in its submission to Parliament.
Image source: Getty/Gallo
Sama raised many concerns and queries about unclear aspects in the 2018 draft Bill, and objected to many aspects proposed to be written into law. Examples include contracting and payment mechanisms which have never been implemented in the country before, as well as missing detail on quality of care expectations. There are also concerns about the amount of power which the Bill hands to the minister of health.
Sama ran a membership survey in November 2019 to gauge the feelings of its membership in relation to the Bill and the NHI proposals. It received 1,000 responses in the short two-week period in which the survey was open. Members do not think that a single fund is the only answer to securing universal health coverage for the population, and the membership is generally concerned about the lack of detail in contracting mechanisms, accreditation procedures and quality of care in general. The written responses indicate a deep mistrust of the government structures in general and the ability of the Department of Health to implement their plans in realising coverage for all.
Members agreed that the proposals for payment arrangements in the Bill are premature, and untested in the South African environment. Overall the Department of Health should pursue quality and finance improvement initiatives already proposed for the public and private sector before fundamentally changing the healthcare delivery system in the country.
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Back pain is a common problem – 80% of us will experience an episode at some point in our lives. It is associated with many factors that vary from person to person but can be caused by an injury, a disc or joint problem, an irritated nerve root or poor posture. The pain might be acute or chronic but living with either can be debilitating.
Pain is considered chronic if it lasts more than three months and exceeds the body’s natural healing process. Either way, failing to get pain relief after different treatments is very frustrating. It can lead to depression, loss of working hours, extensive treatments and often sufferers lose hope and resort to popping painkillers or going for surgery. Both of which can be counterproductive.
Surgery not the only option
Many people assume that surgery is their only option to treat severe back pain. However, according to Dr Jacques Gilau, clinical head for Dr JJ Gilau and Partners utilising Documentation Based Care (DBC) technology in South Africa, ‘only a small percentage of people with back pain require surgery.’ DBC uses effective methods of musculoskeletal rehabilitation and physiotherapy for back and neck pain. Usually a 6-week interdisciplinary programme that includes treatment by doctors, physiotherapists and biokineticists.
Bonitas Medical Fund has partnered with DBC so that its members have access to a back and neck programme of up to six weeks, to either prevent surgery or, when it is unavoidable, prepare and strengthen ahead of surgery and rehabilitate afterwards.
Lee Callakoppen, Principal Officer of Bonitas says, ‘We believe in the preventative management of chronic back and neck pain and since partnering with DBC have received excellent feedback. Members are staying active, developing a better understanding about their pain, identifying the factors involved in their pain and living regular lives. For this reason we cover the full DBC treatment programme.’
According to the DBC statistics, the success rate for treating chronic back and neck pain to avoid surgery is 91% at two years follow-up. DBC has 18 equipped centres in South Africa and the treatment programme is for up to 6 weeks, after which time there are check-ups to ensure that the home programme is effective.
Back, neck and shoulder problems affect many people and are often the result of stress and lifestyle specific issues. Those receiving treatment at the DBC centres range from between the ages of 11 and 93.
Bonitas does not wait for members to contact the scheme when they need help, as part of the Managed Care programme, they use predictive modelling capabilities to support members who may benefit from this service by proactively contacting them and encouraging them to join the DBC programme.
One patient who was contacted by Bonitas when she was suffering from chronic back pain tells her story.
Bonitas back and neck programme give woman her life back
Thandiwe* has Lupus, a systemic autoimmune disease that occurs when your body’s immune system attacks your own tissues and organs. Inflammation caused by Lupus can affect many different body systems — including your joints. She has already been through two hip replacements, surgery to both shoulders, her right knee and her ankle. In 2018 when she started developing lower back pain that went down into her thighs and knees, she knew the disease had started to affect her back. She had to use either a walker or a wheelchair.
She says, ‘I couldn’t walk because of the sharp burning pain. I went to see an orthopaedic surgeon and a neurologist and they confirmed that Lupus was affecting my spine.’ Thandiwe was not a candidate for surgery and was at her wits’ end. Besides not being able to walk she couldn’t do house chores, go the mall or visit family or friends. ‘The worst was when the pain sort of locked my knees, even making standing painful.’
Bonitas, with whom she has been a member for 28 years, phoned her during this time and told her about the DBC back and neck programme.
The doctor at DBC said that her lower lumber vertebra, L4 and L5 are degenerating and that the multi-disciplinary programme of healthcare practitioners would help her.
The six week programme started immediately and she said that apart from consulting with the doctor she saw various therapists and had a range of treatments, including, deep tissue massage, dry needling and thermal therapy. DBC creates a customised set of therapies according to the patient’s particular needs. ‘Initially using the exercise equipment was very difficult but I felt more comfortable once the doctor checked my progress and gave advice.’
She says after a month, she started to walk slowly without a walker and didn’t need her wheelchair. ‘I felt much better and the doctor was pleased with my progress but recommended that I continue with the programme.
‘The best part of the programme is the fact that the pain is reduced, at last I can sleep on both sides and turn in my bed and I can also use the exercise equipment without feeling so much pain. I just feel so much better. I can walk around the house without any assistance. I still keep up the exercises I was given.”
Thandiwe is on the Standard option with Bonitas and the entire cost of the DBC programme was covered.
‘Continuous pain makes you feel depressed and you feel as if you have no life. I am feeling so confident and my self-esteem has started to return. I have my life back!
‘I still have a long way to go but it is the best thing I have ever done. I am continuing with my exercises and looking forward to even more improvement.’
Netcare is one of three hospital groups found to dominated the facilities market. Shutterstock
The investigation ran over five years and included over 43 million individual patient records, 11 million admissions, specifically commissioned studies, written submissions, public hearings and seminars. The investigation focused on hospitals, doctors, and funders. Funders include the medical schemes who purchase healthcare on behalf of members, and the administrators and managed care organisations that medical schemes contract with.
South Africa’s Competition Commission set up the inquiry in response to prices in the private healthcare sector which, it said, only a minority of South Africans could afford. The country has a two-tiered health system. About 71% of the population uses public sector, while the private sector serves around 27%.
Ideally competition should translate into lower costs and prices, better quality, and generally more value for money for consumers. In its final report, which was released recently, the inquiry found that competition wasn’t working as it should in private healthcare. The sector was characterised by high and rising costs, significant overuse, and no discernible improvements in health outcome.
Lack of competition
There were a number of factors that – alone or in combination – led to a lack of competition in the sector.
One factor is that three hospital groups dominated the facilities market: Netcare, Mediclinic and Life. They accounted for more than 80% of the hospital beds and 90% of all the admissions. These three hospital groups, both individually and collectively, were able to secure steady and significant profits year-on-year. A few firms owning the majority of the market is an indication that competition may not be working effectively.
Hospitals don’t attract patients, they compete for doctors who admit patients. Most doctors had contracts with the big three. Successful entry by new hospital owners is very difficult as they cannot attract doctors as easily.
Hospital groups are also able to build additional hospitals where they aren’t needed, resulting in an oversupply of beds and ultimately overuse of services.
In South Africa more people are admitted to ICU compared to eight other countries with comparable published data. The inquiry panel estimated that the country could save more than R2.7 billion – or 2% of its current private health care spend – if it halved the number of people admitted to ICUs and improved the care for patients in wards. Only the critically ill should be admitted to ICU. But the inquiry found that some of the patients who were in ICU could have been treated in wards.
There are no measures of quality of care in the public domain. This means that members of medical schemes and funders (who purchase healthcare on behalf of medical scheme members) weren’t able to judge if the care provided by doctors and specialists was effective.
The entire premise of effective competition is that purchasing healthcare services should be based on value – a combination of price and quality. This isn’t possible in South Africa.
There’s no way to assess if the care provided was improving health outcome. This is particularly problematic as the inquiry found significant over-servicing by doctors which cannot be explained by their patients’ level of illness. Doctors use a fee-for-service billing model. This means they bill patients for each service they perform during a consultation. In this system, the more you do the more you earn. This is called a perverse incentive and without knowing the impact of health outcomes neither doctors nor patients know if the extra tests or interventions are worth the cost. They also don’t know if it is improving health outcomes.
The inquiry also found doctors and specialists worked as individuals -– not as a team. There is growing evidence and acceptance internationally that team-based care is better and more cost effective.
Medical schemes compete for younger and healthier individuals. To do this, schemes have created numerous benefit packages. But these packages aren’t comparable. Medical schemes have done this in response to the absence of a mechanism for equalising risk between medical schemes. Medical scheme members do not know what they are paying for. Neither are they able to judge the quality of care.
Recommendations
The recommendations are aimed at creating greater competition, transparency, and accountability on how medical scheme member’s money is spent. They also aim to increase competition on the supply side (hospitals, doctors, and specialists) and on the demand side where funders represent the consumer.
Recommendations include a supply side regulator, whose job will be to:
assist provinces in issuing licenses for hospitals;
assist with a process and a platform for price setting for doctors;
conduct or contract out research looking at cost-effective healthcare interventions, including technology; and
facilitate access to reliable information on quality of health and health outcomes measurement.
To increase competition on the funder’s side, and to improve transparency for the consumer, the recommendations include that all medical schemes offer one comparable insurance package. In addition, government should introduce a mechanism to equalise risk between medical schemes so that they compete on the merits – not on risk or age selection.
What next
The recommendations have implications for the South African governments plan to introduce a National Health Insurance in a bid to level out the playing field between the public and private health care sectors. The plan is that the National Health Insurance will operate as a funding mechanism to move South Africa closer to universal health coverage.
Implementing the recommendations set out in the inquiry report is an essential step towards creating an environment where the purchaser – the National Health Insurance fund – will purchase from a private healthcare market that is competitive with lower costs and prices, and more value for money for consumers.
The National Health Insurance bill talks about strategic purchasing or value based purchasing which refers to using the capacity in the private sector to relieve the public sector. This aligns with the health market inquiry recommendations.
But it needs an independent supply side regulator to enable competitive price setting and coding mechanisms. Codes form the basis on which prices are determined – which is necessary for the National Health Insurance fund to reimburse providers. Value based purchasing also requires implementation of performance and outcomes reporting and monitoring.
Private and public healthcare has been in the news lately and will continue to be a topic of discussion due to the Department of Health’s proposed National Health Insurance (NHI) Bill, the Health Market Inquiry (HMI) report as well as the current socio-economic landscape.
Lee Callakoppen, Principal Officer of Bonitas Medical Fund
Traditionally, this is the time of year when private medical aids present their products, plans and pricing for 2020 to existing members or potential members, so that they can make informed choices. “It is imperative that the decision you make regarding your and your family’s health and wellness is balanced against affordability,” explains Lee Callakoppen, Principal Officer of Bonitas Medical Fund.
“For existing medical aid members, it’s the time to analyse the plan you are on, whether it meets your health needs and compare it to the various options available.”
Medical aid plans can be confusing which is why it’s important to compare the various options and benefits to ensure you find a medical aid that works for you and your family’s health and that is within your budget. For people who have a broker, that should be the first point of call to help you can make an informed decision.
Here are some steps to help simplify the decision.
Analyse your healthcare needs
Completing a quick personal healthcare needs’ analysis will help you determine what level of cover you need. If you have dependants, factor in their healthcare needs too. Consider how much you and your family spent on medical expenses over the past year as a guide and then ask the following:
How often did your family visit a doctor?
Do you require medicine often?
Did you or the family need to visit a specialist?
Are any of you in need extra cover for cancer, HIV, renal failure or any other specific conditions?
How much did you spend on dentistry, optometry and over-the-counter medicine?
Then consider which expenses were once-off and won’t come up again soon (like childbirth) and which are likely to come up again and again (such as flu) as well as chronic conditions like high blood pressure and diabetes.
Check how much cover you require
If you find you hardly claimed (if you are on a medical aid) or have very few medical expenses, then you will need a lower level of cover. However, if you have a large number of medical expenses, you will require one of the more comprehensive plans. Once you’ve established this, you can decide whether you require a full medical aid or a hospital plan.
Are you happy to use a network
Some plans require you to use a specific GP, hospital network and have a list of Designated Service Providers (DSPs). This helps to keep costs down because the Scheme will have negotiated special rates with these services providers. Check whether there is a wide enough network in your area to cover your specific needs.
Check your budget
Once you have an idea of what you might need for the year ahead in terms of healthcare, then it’s time to look at your budget. Decide what you can afford and remember that the rule of thumb is that contributions should not exceed 10% of your monthly income.
Read the small print
Make sure you read all the details, including the benefits. These vary from plan to plan so establish what is covered and look at whether it offers additional risk benefits which can potentially save on day-to-date expenses. These could include anything from free wellness screenings (blood pressure, cholesterol, blood sugar and BMI measurements) through to maternity benefits, flu vaccinations, mammograms, pap smears and HIV tests. All of these are costly if you have to pay for them yourself.
What about savings?
Medical savings are a fixed amount a medical scheme gives you at the beginning of the year. You can use your savings for daily out-of-hospital medical expenses, such as GP and specialist consultations and over the counter medicine. There are ways to maximise your savings but first you need to know what you annual allocation is.
Age can influence the decision
If you have young children, ensure that the medical aid option you select provides sufficient child illness benefits. For young couples looking to start a family, ensure the option provides sufficient cover for maternity benefits. However, if you aging then you need an option that covers chronic conditions and provides sufficient in-hospital cover in the event of hospitalisation.
Some additional advice
Remember to be honest on your application form, disclose all information about you and your dependents’ health. Membership can be suspended or cancelled if you fail to do so.
Any waiting period or exclusions? Schemes may impose certain waiting periods for new members joining or for a pre-existing medical condition. This is based on the guidelines of the Medical Schemes Act and the specific scheme’s rules.
Finally, get expert advice
“Your health and that of your family is important so it is vital that you are comfortable with the choice you make and are confident your healthcare needs will be taken care of,” says Callakoppen. “My advice is to make sure you are informed. Read the information and fine print and compare what the different plans are offering before you commit. If you are still unsure, phone the scheme and ask questions or check with your broker or financial advisor.”
