Choosing Medical Aid

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Most medical schemes have launched their benefits and contributions for 2017 and it is the time when you should be re-looking at your existing medical aid cover or, if you are wanting to join a scheme, investigating which one suits you best.

The medical aid landscape can be tricky to navigate so it is important to compare options and schemes to ensure you find a medical aid that works for you and your family’s health and is within your budget. Dr Bobby Ramasia, Principal Executive Officer of Bonitas Medical Fund, helps guide you through choosing the best plan, whether it’s through the open market or through an employer.

If you are already on a medical aid scheme

Before you choose the best medical aid option, you need an idea of what your typical health care costs are. You should also consider the following for you and your dependants over the past twelve months:

  • How much you spent on day-to-day healthcare expenses
  • Where you or any of your dependants admitted to hospital
  • Did you need to visit a specialist regularly
  • How much often do you or your dependants visit a GP
  • Do you and your dependants have any chronic conditions
  • How much do you spend on dentistry, optometry and over-the-counter medicine
  • Did you exhaust your day-to-day benefits and/or savings this year
  • How much did you pay in co-payments and/or deductibles

 

Then consider which of the expenses listed above 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). You should be able to find a list of your medical claims on your current medical aid’s website.

The day-to-day detail:

Often the cost containment measures medical schemes apply for the day-to-day benefits are broad. So investigate, or bear in mind, the  following:

  • Does your medical aid contract with doctors and specialists and, if so, are you willing to use them? Using contracted or network doctors usually means obtaining full or improved cover levels, while using doctors outside of the network usually results in restricted benefits or co-payments. It also helps ensure you are getting more value for money as doctors on your medical scheme’s network will not charge you more than the rate agreed with your medical scheme.
  • Must you be referred to a specialist by your GP?
  • Does your medical aid offer additional GP consultations, which they will pay for, after you have exhausted your day-to-day benefits?
  • Does your medical scheme offer any additional benefits such as maternity, preventative care or wellness benefits that are paid from risk and not savings or day-to-day benefits?

You can also follow these tips to get more value for money:

  • Use generic medication wherever possible – get into the habit of asking your doctor and pharmacist about this
  • Try to keep your claims within any specified sub-limits, e.g. optometry
  • Find out if your option has any day-to-day benefits that are paid by the scheme from risk (not from your day-to-day sub-limits or savings). Two examples where this sometimes applies are dentistry and optometry.

Additional benefits:

Ask what supplementary benefits might be available to you that can potentially save significant day-to-day expenses. These could include the following;

  • Preventative care benefits, ranging from basic screenings (blood pressure, cholesterol, blood sugar and body mass index measurements) through to mammograms, pap smears, prostrate testing. In some cases this extends to maternity programs, dental check-ups, flu vaccinations and more. These usually require authorisation from the scheme, failing which they are simply met from your day-to-day benefit limits. A mammogram costs in the region of R900, so don’t look a gift horse in the mouth!

Age impacts your 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, check that your option provides sufficient cover for maternity benefits.

However, if you are slightly older then ensure that the option you select covers chronic conditions and provides sufficient in-hospital cover in the event of hospitalisation.

Ensure the affordability of the medical aid plan selected. When comparing the different medical aid options available, consider all the costs involved before you make your final decision, such as:

  • The monthly contributions, as a rule of thumb, you medical aid contributions should not exceed 10%of your monthly income at an individual or household level
  • Other costs associated with your medical aid option e.g. if your option only allows consultations with doctors on a network, then you must ensure that the cost of travel to a network doctor (including hospitals and other healthcare service providers)
  • The cost of co-payments for various benefits claimed. A medical aid co-payment is a fee that the member is liable for when making use of certain medical services. The medical aid would not cover 100% of the costs and the member would have to pay for a certain percentage of the medical service before the medical aid pays their portion.
  • These co-payments usually apply to specialist or elective medical procedures. This will differ from one medical aid scheme to another. It is one of the reasons why you should always do thorough research before deciding which medical aid scheme is the best option for you. The ideal option would of course be the one that does not require many or any co-payments from the member.
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