Source: Johan van Tonder

When planning a family – and even when your pregnancy is unplanned – one tends to consider all kinds of important matters; what to name the little one - is a family name appropriate; where will the little tyke go to school; will one be able to afford proper schooling?

Few parents at the outset plan their pregnancy with their medical scheme cover in mind – but that is exactly what should be done. Before deciding to expand your family, it is imperative to review your medical scheme cover to ensure that you will be fully covered for the cost of care during the pregnancy and birth.

If you are already expecting a child, and are not covered on a medical scheme, you may find that medical schemes are not too keen to offer you cover, and even switching between benefit options to make provision for proper cover may turn out to be a nightmare. Most schemes will apply a waiting period and/or exclude you from maternity benefits for at least 12 months when joining afresh. One exception is when you move as part of an employer group.

In South Africa, the law dictates that benefit option changes are only allowed in January of every year. So if you are planning to get pregnant in the coming year, it is wise to upgrade your cover at the start of a new year.

Best advice will be to find yourself a reputable medical scheme broker who will be able to advise you on the best option going forward.

When talking with your broker, check the limits on maternity benefits your current medical scheme option offers, and calculate whether it will be sufficient. Also consider that your baby may be born with health problems, making it necessary to be able to increase cover if necessary.

Some schemes limit the amount paid for the delivery; some combine the delivery fee with ante-natal care benefits, such as scans and tests necessary during pregnancy. Also ascertain whether you will have to consult within a specific network of providers in order to access the benefits, and whether these facilities are conveniently situated to where you are.

Ensure whether a specific limit for maternity benefits applies only to the hospital bill for the delivery or whether it includes the practitioner’s fees, and especially make sure of what co-payments, if any, applies. Often specialist practitioners charge more than the guideline tariff, and the member remains liable for the difference.
When the gynaecologist or GP announce the good tiding of your pregnancy, ask for a typical treatment plan and ensure that all the relevant procedure codes, ICD10 codes and related information is stated. Supply this to your medical scheme and ask up front what benefits you are entitled to, and what co-payments you will have to foot. If your scheme combines in-hospital and out-of-hospital maternity benefits, check if the limit is sufficient for the tests you may require, such as a six-week check-up for you and your baby, amniocentesis tests, and procedures and medication you may need as the pregnancy proceeds.

Also ask your broker about the maternity benefits your scheme’s loyalty rewards programme may offer. Some medical schemes will pay for certain benefits such as government regulated immunisation up to a certain age from their loyalty programmes, or from their value added products or preventative care benefits, at no extra cost to the member. Their value-added products may even pay for certain gynaecological consultations annually.

Every parent hopes for a healthy, happy, chubby little baby. In certain instances, such as an older mother, the pregnancy may be fraught with additional dangers, and will require expert financial planning. It remains imperative that the prospective parents consult with a knowledgeable healthcare broker to guide them through the quagmire of medical scheme benefits and options to make the experience the true magic it is meant to be.