Access to good healthcare remains a concern for most South Africans and choosing a medical aid to suit your financial status and needs, can be very confusing. Not surprising considering that, according to the Council of Medical Schemes, there are 83 medical aids operating in South Africa. Added to the mix is the recent announcement by the Minister of Health of the proposed National Health Insurance (NHI) scheme.
With all the options offered by medical schemes, which include everything from comprehensive cover to a simple hospital plan, how do you make a choice? Gerhard Van Emmenis, Principal Officer of Bonitas Medical Fund, provides some pointers to help make the decision easier. He cautions, however, that due diligence and some homework is required ahead of making a final decision.
The most important factor is to know what you and your family need in terms of cover and what suits you best:
- Reflect on your family’s health history to gauge the number of visits you make to the doctor and the cost of medication
- Whether anyone has a chronic condition or needs to see a specialist
- How much you spent – or need to spend – on dental or eye care
- If you already have a medical plan check what was covered, how much your co-payments (if any) were and whether your savings for the year were adequate.
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. What can you comfortably afford to spend to get the medical cover you need? (The rule of thumb is contributions should not exceed 10% of your monthly income). ‘Once you have these two scenarios then it’s time to compare the various plans and see which best matches your needs and budget,’ says Van Emmenis.
Benefits vary from plan to plan so check what is covered by the one you are considering and look at whether it offers supplementary benefits which can potentially save significant day-to-date expenses. These could include anything from 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.
In terms of the Medical Schemes Act, there are 26 common chronic illnesses, known as Prescribed Minimum Benefits (PMBs), which all options on all schemes are required to cover for medication and treatment.
What are savings?
One of the most misunderstood elements of medical plans is how the day-to-day benefits work. ‘Medical savings are a fixed amount that the medical scheme gives you at the beginning of the year,’ explains Van Emmenis. ‘You can use your savings for daily out-of-hospital medical expenses, such as GP and specialist consultations and over the counter medicine. It is imperative that members use their savings and day-to-day benefits wisely to get maximum value for money.’
How can to make the most of savings?
Always use partner networks
Medical schemes negotiate preferential rates with these partners. This means if you use a network hospital, doctor or pharmacy you will not be charged more than the rate agreed with the scheme. This will also help you to avoid co-payments, deductibles and additional out-of-pocket expenses.
Find a GP on your medical aid’s network
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 Medical Fund has the largest network of GPs in South Africa – with over 5 500 doctors.
Register all chronic diseases
If you’re on regular medication to treat a chronic illness (such as Diabetes, hypertension or hypothyroidism) you could qualify for chronic medication benefits. This means that your medical scheme pays for it out of the risk portion of your medical aid and not your medical savings account. All you need to do is register your condition as chronic.
Make use of preferred providers
Medical schemes often have providers that are contracted to them. Members are then given better rates for specific benefits. For example, Bonitas has contracted the services of DENIS for dental benefits.
Use formulary meds
All medical schemes have a list of medication they cover called a formulary. Another way to avoid co-payments and out-of-pocket expenses is to ensure your doctor treats you with medication listed on your plans specific formulary. Where applicable, you can also use a Designated Service Provider to obtain your medicine and stretch your benefits even further.
Managed care benefits
Some schemes offer preventative care benefits, which are paid from the risk portion of your medical scheme and are not funded from your savings account. This includes Oncology, HIV and Diabetes management programmes.
Ask your pharmacist
Pharmacists too can provide sound medical advice on problems such as rashes, colds or illnesses that are not severe. Buy over-the-counter medicine to treat less serious ailments and consider using generic medicine which is cheaper but effective.
What is Gap Cover?
Gap cover is an insurance policy you can take out to help pay for the shortfall between what your medical scheme pays and what the hospital or specialist might charge. The amount paid out depends on your policy but most people usually combine Gap Cover with a hospital plan. It is important that note that Gap Cover is not offered by medical schemes and is a separate health insurance product.
As of 1 April this year, the same requirements for a medical scheme have been introduced including a waiting period of between 3 and 12 months for certain conditions and payout limit of R150 000 a year for each person.
And a hospital plan?
This provides you with basic, yet important medical cover and essentially covers all your required in-hospital procedures and check-ups, including the 27 chronic conditions (or PMBs).
However, a hospital plan does not provide cover for day-to-day doctors’ visits, prescribed medications, chronic medication and related expenses. Some hospital plans offer value-added benefits, so read the fine print, ask questions to make sure you are getting what need.
‘The best advice I can offer is to be informed,’ says Van Emmenis. ‘Take the time to read the information and fine print, compare what the plans are actually offering. If you are unsure phone the scheme and ask questions, or check with your broker. 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.’