Understanding medical scheme options

Medical schemes have various benefit plans available to members. Members have to choose between hospital plans, hospital plans with a savings component (New Generation Options), traditional plans, comprehensive plans and network plans.

If your savings benefit is quickly depleted at the beginning of the year and you have to pay for expenses out of your own pocket, or if your option is too expensive, it would be worthwhile to reconsider your particular medical plan. Certain schemes allow migration to other options mid-year, while others allow such changes only at the end of the year.

Traditional Plans
Cover almost all medical expenses and include benefits for in-hospital, day-to-day expenses and chronic medication, subject to the rules of the scheme.

These plans are recommended for individuals or a family who wants comprehensive cover, but does not want a savings benefit on there option. These options still cover emergencies, hospitalisation, day-to-day expenses and chronic medication.

Mr Deon Heydenrych, senior corporate consultant of Optivest Health Services, says Traditional options are very expensive. "Also, they do not have a savings component and consequently rather limit out-of-hospital benefits, for example allowing 15 visits to a general practitioner or R1 500 for dentistry. If the benefit is not utilised, it falls away at the end of the year, whereas a savings benefit of a new generation option is carried over."

Comprehensive Plans
These options have a savings component and cover almost all medical expenses and include benefits for in-hospital, day-to-day expenses and chronic medication, subject to the rules of the scheme.

These plans are recommended for individuals or a family who want comprehensive cover for emergencies, hospitalisation and day-to-day expenses and that makes use of quote a lot of chronic medication.

Comprehensive options have got Threshold levels build into the benefits, which means the following: Once a member’s savings is depleted and the member gets any day-to-day treatment (GP, specialist, dentistry, x-rays) which he pays for himself for there is no more savings available, then those invoices must still be submitted to the scheme. The reason for that is, that once the member has spend a specific amount form his own pocket for day-to-day expenses (depending on the option he is on), he has reached the Threshold level and the scheme will start to pay for day-to-day expenses form there side at normal medical scheme rates and with sub-limits.

These are options for families or individuals who has a lot of day-to-day expenses and who claim a lot.

Basic Hospital Plans
Cover accounts submitted by service providers only for in-hospital expenses.

You are responsible for your own day-to-day medical expenses, including emergency ward treatment.

Hospital plans cost considerably less than comprehensive medical plans. However, Heydenrych recommends that you first determine the difference between the premium of a hospital plan and that of a comprehensive plan before making your choice.

"Basic hospital plans are recommended for an active and healthy family. If you take responsibility for your own health and know that prevention is better than cure, it will work for you. However, the disadvantages include co-payments on certain procedures such as gastroscopy, colonoscopy, laparoscopy, extraction of wisdom teeth, cataract removal, etc. Some procedures might also not be covered at all.

"It is also important to know at what medical tariff you will be covered while in hospital, for if the specialist and anaesthetist charge you more than what the medical scheme covers, you will be responsible for the co-payment," says Heydenrych.

Hospital Plans with Savings ( New Generation Options)
Cover accounts submitted by service providers only for in-hospital expenses.
You are responsible for your own day-to-day medical expenses.
Cost less than comprehensive medical aid plans.

The medical savings plan is designed to cover day-to-day expenses. The member contributes a fixed monthly amount to a savings account. The total annual amount available in the savings account is available in advance for medical expenses.

Such plans are recommended for individuals and families who require comprehensive cover if they need to go to hospital in case of an emergency or for a planned procedurt, and also want to enjoy the flexibility of a savings account for those day-to-day expenses.

Remember, if your savings run out, you as the member will have to pay for any further day-to-day expenses out of your own pocket.
Look out for co-payments on certain procedures like gastroscopy, colonoscopy, laparoscopy, extraction of wisdom teeth, cataract removal, etc.
Some procedures might not be covered.
And ascertain at what medical tariff you will be covered while in hospital, for if the specialist and anaesthetist charge you more than what the medical scheme covers, you will be responsible for the cost.

Capitation or Network Option
Provide individuals with basic day-to-day cover at affordable prices at specific network providers. Network providers differ from scheme to scheme and the relevant list is available from the scheme.

This is recommended for young families with small children, who want the freedom to take children to the doctor, dentist, etc. It might also be a good option for someone who cannot really afford full medical aid or can afford only a basic Hospital Plan but still wants some peace of mind concerning hospitalisation.

Heydenrych says the drawback is that members may make use of only certain doctors, specialists, pharmacies and hospitals. Sometimes co-payments also apply and certain procedures such as neck and back surgery, knee and hip replacements are not covered.

Heydenrych suggests that members ask the following questions before making their final choice regarding the best option for them:

Would I be limited to a network of hospitals?
What rate of hospital reimbursement is applicable?
Do I need additional chronic medication cover?
To what extent do I need day-to-day cover?
What contribution can I afford?
What is my family composition?
Any future planned procedures?
Current health conditions and family history?

A final tip for members: It is essential to evaluate your medical scheme annually. Heydenrych says, "If you notice that your savings benefit is used up quickly at the beginning of the year and you have to pay all your other day-to-day expenses, it would be worthwhile to reconsider your option. Look at your contribution to your savings benefit and what your day-to-day expenses out of your own pocket amount to additionally per year. Also look at the total amount and compare it with a more comprehensive plan. What is most important is to obtain independent advice to enable you to make an informed decision regarding your choice of medical scheme."


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