Medical Aid choices

It’s business as usual for medical aids…

While the NHI remains a work in progress in terms of policy and planning, currently nothing changes in terms of medical aid schemes. As the NHI White Paper stipulates: Until the new system is fully implemented and operational, it is ‘business as usual.’  And, even when NHI is implemented, medical aids will still exist. 

According to Gerhard van Emmenis, Principal Officer of Bonitas Medical Fund, South Africa’s second largest open medical scheme, one of the changes that will be seen once the NHI is a fait accompli, will be a decline in the number of medical schemes. ‘From what I understand, and we are talking of the future, there will be three or four medical aids which will serve as complementary health product providers and fill the gaps left by the NHI.’

Medical Aid ‘launches’ will go ahead in September – when schemes announce amended plans and premium increases for 2019. 

Costs of medical aid

It is also the time when new members sign up and existing members scrutinise and review their existing cover, whether it’s a full medical aid or hospital plan.  Medical aid may seem like a grudge purchase until you find yourself faced with unexpected and expensive medical cost. Unfortunately, healthcare inflation continues to outpace general inflation by about 5%. So while consumers are struggling in the economy generally, medical aids have to explore ways to contain costs without compromising the level of health care offered to members.

Time to scrutinise the small print

The medical aid landscape can be tricky to navigate so it’s important to compare all the available options and schemes to make sure you find a medical aid that works for you and your family’s health and is within your budget. Bonitas offers some advice on what to look out for and consider ahead of making a final decision. 

If you are already on an existing medical aid 

Before you decide on the best medical aid option, you need an idea of what your typical health care costs are. Reflect on the following over the past twelve months:

• How much you spent on day-to-day healthcare expenses 
• Were you or any of your dependants admitted to hospital 
• Did you need to visit a specialist regularly 
• How often did you visit a GP
• Do any of you 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 in the 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 (such as childbirth) and which are likely to come up again and again (such as flu). 

Empowering yourself with information

Also take the time to read the information sent to you by the scheme and/or your broker to ensure you understand what it being offered so that you can make informed choices.  

The day-to-day detail for new or existing members

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 hospitals, doctors and specialists and, if so, are you willing to use them and are they close by? Using contracted or network providers usually means obtaining full or improved cover levels. It also helps ensure you are getting more value for money as doctors on your medical scheme’s network will not charge 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? 

Additional benefits

Ask what supplementary benefits might be available 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, prostate testing. In some cases this extends to maternity programmes, 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. 

Ways to get more value for your money

• Use generic medication wherever possible – ask 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)
• Using network doctors is an invaluable tool to make your medical aid last longer. It means that doctors can’t charge you more than a specific amount. At present, Bonitas has the largest GP network in the country. 

Age impacts your decision

• If you have young children, ensure that the medical aid option you select provides sufficient child illness benefits
• Check the maximum age of child dependents.  Some allow students to remain on the scheme until they are 25, while others cut off at 21 or 23
• However, if you are slightly older, then check that the option you select covers chronic conditions and provides sufficient in-hospital cover in the event of hospitalisation. Also keep an eye out for programmes that help you to manage chronic conditions such as diabetes and cancer. 

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:

• Affordability of the monthly contributions given your monthly income and expenses.  As a rule of thumb, your medical aid contributions should be around 10% of your monthly income at an individual or household level
• As a general rule, the lower the cost of the option the fewer the choices available to the member regarding medical treatment, healthcare providers and medications.
• However, this can greatly benefit people who have very limited resources available to them for healthcare, or for people who don’t have chronic and existing conditions and are relatively healthy. The cost of co-payments. A medical aid co-payment is a fee that the member is liable for when making use of certain medical services. When the medical aid doesn’t cover 100% of the costs and the member is required to pay 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 differs 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. 

Some additional advice

• Disclose all information about your and your dependents’ health. Membership can be suspended or cancelled if you fail to do so
• How good is the payment record? Phone your GP’s receptionist and find out whether they have experienced problems with pay-outs from that particular scheme
• Check a scheme’s solvency ratio. According to the law, schemes should have at least 25% of members’ annual contributions in reserve  
• Scrutinise the table of benefits. Things might look good on paper but do check what the day-to-day limits are and how much your Medical Savings Account is per year. If small, you could exhaust your day-to-day cover quickly. Also remember that many private hospitals don’t charge medical scheme rates so check what
  co-payments you will have to make on all bills 
• 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. Bonitas recommends that you enquire with the relevant scheme about their exclusion list and waiting periods.  

Don’t forget that you do have the option to use an independent broker who will help you choose the medical aid plan best suited to your and your family’s needs.