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It’s time to do an annual review of your medical aid plan

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Decoding your medical aid terms and conditions and associated costs is not an easy task. As we approach the end of November, time is running out to decide which medical scheme and plan will best suit your needs in 2019.

Here are a few pointers for you to consider:

 

  • Before starting your research, remember that you get what you pay for

Medical Aid Schemes operate on the principle that the contributions received from members should cover any claims paid out. The way to control this is to limit the benefits based on what you can afford to pay. This is why there are so many varieties of plans offered at different price points. There is a direct correlation between cost and benefits – the more the plan costs the more the benefits. As a guide, consider how often you may need to use your medical aid. The more frequently you use your medical aid, the more comprehensive your plan will need to be. Be cautious of very cheap plans with hospital cover – you get what you pay for, and will no doubt have a limit in your hospital cover or a massive co-payment. The better plans have unlimited hospital cover which means you won’t have to leave after a few days, allowing you to stay for as long as the procedure or recovery period requires.

  • Don’t make hasty decisions based on immaterial value adds

While medical aid loyalty programmes have become a big attraction for some (with cheaper movie tickets and gym memberships), be careful not to make this the sole driver when deciding on a medical aid. These are just ‘bells and whistles’ and can distract you from some of the not so great aspects of your medical aid plan. All these ‘nice to have’ benefits won’t pay for your medical bills when you need it.

  • Start by understanding the cover you already have and how it may change for 2019

It’s no secret that the average consumer in South Africa is feeling the pinch of a tough economy and may be looking for ways to reduce monthly living expenses. The following average weighted medical aid premium increases were announced for 2019:

 

  • Bonitas – 8.9%
  • Bestmed – 9.9%
  • Discovery – 9.2%
  • Fedhealth – 8.4%
  • Genesis – 6.5%
  • Momentum Health – 10.7%
  • Medshield -14.5%
  • Topmed – 9.9%

 

Unfortunately for the consumer, all these increases in membership contribution rates are significantly higher than general inflation which is currently at 4.8%. Also bear in mind that schemes need to contain their costs in the face of increasing claims, and in some instances may have changed some of the benefits you have enjoyed on your current plan. For this reason, an annual review of your plan is essential. You won’t want to find out down the line that you are no longer covered for something that you were covered for before.

  • Decide what benefits are the most important to you and your family for 2019

Most people choose their medical plan based on cost, the levels of medical cover provided, day-to-day limits on medical expenses and chronic benefits. While this is not wrong, there are some other factors to consider as well. Be sure to study all the benefits in line with your needs and then compare costs. Avoid choosing on cost alone.

Administration – Get an idea of who administers the scheme and if they have a good track record in processing claims. On occasion, you may need to fund a doctors account upfront. You don’t want to be in a situation where it takes months to get your money refunded.

Reimbursement Rate/Coverage – Most schemes pay claims at between 100% to 300% of their own Medical Scheme Rate which is created using the National Health Reference Price List (NHRPL) as a guideline. If you need to settle for a plan with lower coverage, then you might want to factor in gap cover, an affordable insurance product that covers the shortfalls on in-hospital specialist expenses.

Exclusions – Medical plan brochures are great at punting the benefits of the plan, but what about exclusions? These are as important in terms of what is covered, and this can change from year to year.

Co-payments – Co-payments on certain procedures are common but often overlooked when choosing a medical aid plan. Nobody expects to go into hospital or to undergo certain procedures. However, investigating these upfront as part of your annual review is critically important. Co-payments are expenses that you will have to fund out of your own pocket should they occur. Co-payments differ from scheme to scheme and sometimes depend on whether the procedure is done in or out of the hospital.

Preferred Provider Networks – More and more medical schemes are negotiating preferred rates with their own network of doctors, specialists, pharmacies and hospitals in order to contain costs. Using a doctor or provider outside of this network could result in penalty co-payments and/or claim rejections. Before you choose a plan with these stipulations, first make sure your preferred service provider is covered and/or part of the schemes network.

 

In summary, to find the right medical aid scheme and plan for your needs will require thought and time. You need to be comparing at least five of the top medical aids in South Africa before deciding.

If all of this seems too overwhelming, there is an easier way. Medicalaid.co.za has an instant comparison tool that allows you to compare benefits and price all in one place. The comparison looks at a monthly premium, hospital choice, overall annual limit, cancer cover, reimbursement rate, day-to-day cover, benefits, MRI/CT scans, maternity benefits and chronic cover.

This is a great way to get started and can save you a lot of time. Visit www.medicalaid.co.za now and make an informed decision for 2019.

How to review your medical aid for 2019

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It’s now time to review your medical aid scheme cover for 2019. This means you have a window within which you can switch to a different plan for the new year. This window usually closes at the beginning of December (depending on your current provider), so don’t delay collecting the necessary information. This is not a decision to be rushed.

Why do I have to decide now?

Medical aid providers allow you to switch plans once a year (at the end of the year) without penalties or consequences. If you want to save on premiums or you need to increase benefits, now is the time to do it.

What if I want to change providers altogether?

If you are unhappy with your medical aid provider, you can switch to another at any time of the year. But before you do, consider the following:

Waiting Periods

Medical Aids by law must accept anyone who applies to join their scheme. To protect themselves from older or sickly members that join without having contributed to the risk pool, they usually impose a waiting period of between 3 and 12 months.

Waiting periods will apply if 1) you have not been a member of another South African medical aid for the past three months or more, 2) if you change medical schemes before 2 years of being covered with your previous medical aid provider and 3) if you have a pre-existing medical condition.

Finding out about any waiting periods is extremely important before deciding to change providers.

Late joiner penalty

As an additional means to manage the risk of older or sickly members joining without having contributed to the risk pool, medical schemes (according to the Medical Schemes Act) are entitles to add a late joiner penalty to your premium if you were not part of a medical scheme before 01 April 2001. The late joiner penalty is calculated (using a prescribed formula) based on the number of years that you were not on a registered South African medical scheme. The late joiner fee can range between 5% and 75% of the total contribution, depending on the number of years that you were not covered by a medical scheme.

How do you know that you are in the right medical scheme?

Understanding how your medical benefits work is a daunting task for most. For example, your scheme might cover you for 100% of hospital costs at the medical fund rate. You might think that this means all in-hospital costs will be covered. Unfortunately, many uninformed South Africans are left with an enormous hospital bill for making use of a specialist that charges more than the medical fund rate. This is just one example of what could be overlooked when selecting the right benefits for yourself and your family.

Here are a few tips to follow and questions to ask when reviewing your current or future medical plan:

Do you understand the various benefits and their associated costs?

Before you make any decisions, you need to familiarise yourself with certain medical terms and jargon. Understanding these terms could save you money. You may be paying for something you don’t need, or perhaps you aren’t properly covered for something you do need. Now is the time to find out.

Here are the “Top 5” terms you should understand before reviewing your medical aid for 2019:

Exclusions

This is very important as it tells you exactly what is not covered. Be aware that this can change from year to year. Just because something was covered in 2018, does not mean it is automatically covered in 2019. Make sure to check this to avoid any nasty surprises when you try to claim.

Co-payments

Most medical schemes apply co-payments that you need to fork out before undergoing certain procedures. These are different depending on the scheme and plan you select and are also subject to change. Co-payments can apply for in- and out- of hospital procedures. Check this detail in your medical plan brochure, especially if you have identified any upcoming medical events for 2019.

Prescribed Minimum Benefits (PMB’s) and chronic medication

In terms of the Medical Schemes Act, regardless of the benefit option, you have selected, there is a defined list of benefits/treatments for which all Medical Aid schemes in South Africa have to provide cover for. This includes covering the costs related to the diagnosis, treatment and care of an emergency medical condition; a limited set of 270 medical conditions; and 25 chronic conditions.

Important to note when it comes to chronic medication, is that schemes can impose preferred providers and sometimes only pay for generic versions of medication. This essentially means that you need to get your medication from the medical scheme’s appointed service provider or you will need to fund a co-payment out of your own pocket for your chronic medication.

If you have a persistent condition, check if it is listed as a chronic condition and then check that the medication you use is also covered. Some medical schemes have additional chronic conditions that they cover over and above the 25 that they are obligated by law to cover. These additional conditions could change, so again if you were covered this year, don’t assume it will be covered in 2019. Rather do a double check to avoid surprise expenses.

Preferred provider networks

Most Medical Schemes have service provider networks with whom they have negotiated rates to contain costs.  These networks include pharmacies, GP’s, specialists and hospitals. If your healthcare provider is not one of these network providers, you will be liable for a co-payment.

Coverage

Coverage can vary dramatically from one scheme to the next. It can also change from year to year. These changes are usually announced with the annual price increases. Most schemes pay claims, at between 100%-300% of their own Medical Scheme Rate. There are two things you need to do here; 1) find out if your doctor charges Medical Scheme Rates and 2) negotiate rates with specialists prior to treatment. If they charge above Medical Scheme Rate, and the procedure was not considered by your scheme to be an emergency, you may be liable for the difference in costs between what the specialist charges and what your medical scheme has agreed to cover. Of course, if you have taken out gap cover, any of these in-hospital expense shortfalls will be covered.

What does 2019 look like?

Do you have a medical condition now that you anticipate will drain you financially? Or are you anticipating a medical event like childbirth or dental treatment? Maybe you’ve been putting off a knee replacement or other surgery, but it can’t go unattended any longer. If this is the case, you should consider upgrading your plan and should at very least be adding gap cover, which will cover any payment gaps between what your medical aid pays out and what specialists charge you while in hospital.

Could a doctor network benefit you?

Most medical aids have their own network of doctors and hospitals. If the network is convenient for you to use, then changing to a ‘network’ plan could mean substantial discounts on your monthly medical aid premium. If saving money is a major priority for you, then find out if the medical scheme provider you are currently with has a network and if they are in your area, then if they are acceptable to you, consider downgrading your option.

How long did your savings account last this year?

Did you run out of savings halfway through the year? Or maybe you have a surplus left over. You need to calculate how much you spent on out of hospital and day to day medical expenses in 2018. This way you will know if you should be seeking a plan with a bigger savings portion. If you have a surplus, this will carry over to next year, which may allow you an opportunity to downgrade to a plan with a smaller savings portion. This is most probably the most time-consuming part of reviewing your medical options for next year. You will need to look at all your slips and bank statements to calculate how much you need for unforeseen/seasonal illness. You may find your major costs are during the winter months. Knowing this upfront will allow you to plan better and perhaps put aside additional money into secondary savings account so that you have funds available when your medical savings account runs dry.

How much is your medical aid increasing premiums by?

Unfortunately, medical aid premium increases are usually above inflation and in many instances more than annual salary increase rates. This means that your medical aid contribution is one of your biggest expenses, right up there with home loan repayments/rent and vehicle repayments. Whether or not you can still afford your current plan is a major factor in your decision for 2019. This alone may force you to downgrade. Before you do, carefully consider the loss of benefits and the risk you are taking. You may find there are other items in your budget you should rather be cutting out, especially if you have identified future medical events in 2019.

My medical aid savings have run out

What to do when your medical savings runs dry before the year is over

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As we come out of the winter months and the flu season, many of us have depleted our medical savings. While it’s too late to do anything about this year’s savings, there are things consumers could and should be doing to avoid this happening again next year.

 

Consumers need to break the medical savings abuse cycle

As soon as consumers realise that their medical savings is depleted before the end of the year, what usually happens is that they delay seeking the medical attention they require between the time that their medical savings runs out and 1 January of the following year.

They may for example, be tempted to leave that cavity in their tooth for a while and just ‘eat on the other side’ or put off their check-up with the gynae for a month or two. Maybe they even decide to forgo those monthly vitamins that they were paying for out of their medical savings. In doing so, by the time the new year presents itself, they find themselves with a ‘backlog’ of medical needs, some which by this stage require more medical care than if they had simply dealt with them when they occurred. The end result is that by February many have eaten into a large percentage of their annual medical savings allowance.

Ideally, when January comes around and medical schemes ‘reset’ their medical savings to its full amount for the new year, consumers should be in a position where they have no backlogged medical procedures to rush to. This sounds great, and makes a lot of sense, but how exactly can they pull this off?

 

Health first! Consumers should cut back on other expenses to proiritise their health between now and January

The goal is to remain healthy for the remainder of the year. Sounds obvious, doesn’t it? Instead of giving up those vitamins, consumers should rather give up on eating out? Looking after health needs in the short-term will help them to reduce their medical costs in the first quarter of next year and will help their medical savings to last longer. As part of a stay healthy plan, consumers should also remember to make use of their medical schemes preventative screening benefits and should focus on a healthy lifestyle which includes exercise, dieting and cutting back on bad habits like smoking and drinking. It is better for them to set aside that money as a medical saving for themselves while they are in a self-payment gap.

 

Consumers can reduce their medical costs by being smart

If consumers find themselves getting sick while in a self-payment gap, then they should consider the following ways to save on medical expenses during this period:

  1. Not everything requires a doctor’s visit. In many cases, pharmacists are skilled enough to provide sound medical advice on problems such as rashes, colds or other minor everyday illnesses. Consumers should rather get an opinion from their pharmacist first before running up unnecessary doctors’ bills.
  2. When consumers need over-the-counter medications such as headache tablets, vitamins, antacids or flu meds, they should first try purchase them from a supermarket rather than a pharmacy. This could save them heaps of money, as supermarkets buy in bulk and are able to pass on savings to their customers.
  3. If consumers do have to spend money on medication, they should ask their doctor to prescribe a generic form of the medication needed. They should also then double check with their pharmacist that they are given the cheapest generic alternative available. Unless specifically ruled out by their doctor, they should opt for a generic as they are often a lot cheaper and do the same thing as the original brand name medications. Some generics are even manufactured by the same original brand on the same assembly line, and only the packaging is different.
  4. Consumers can also avoid using multiple medicines when as an alternative, they can purchase one that takes care of all their symptoms. For example, why get one type of medicine for a runny nose, another type for a sore throat and a third type for a fever. If they ask their pharmacist, it very likely that they could get an ‘all-in-one’ medicine at half the price that will take care of all their symptoms.
  5. Consumers that find themselves on regular medication, should check if their condition is listed as a chronic condition with their medical scheme. The same should be done if they receive a new diagnosis that requires ongoing medication. There are 27 chronic illnesses that all medical schemes must cover. While medical schemes don’t have to pay for the diagnosis of the condition (while the consumer is in a payment gap), as soon as you have a diagnosis, the medication could be covered by the consumers chronic medication benefits. Many people don’t realise that they need to submit their prescriptions to their medical schemes in order to claim from their chronic medication benefits and end up paying for these medications out of their own pockets. Some of the more well-known chronic conditions include asthma, diabetes, epilepsy, hypertension, rheumatoid arthritis and bipolar mood disorder. Some medical aids cover additional chronic conditions such as attention deficit disorder, depression, anxiety disorder, post-traumatic stress disorder and more, depending which medical scheme option the consumer belongs to.
  6. Consumers should make use of their rewards programmes. There are a number of retailers that offer cash back, two-for-one or three-for-two specials on vitamins and other health products. Where possible, consumers should use these benefits to subsidise their monthly health expenses.

 

Plan better for the new year

Assuming consumers follow all the advice above and arrive in the new year with no backlogged medical needs, they are in a great position to plan and budget so that they don’t find themselves in this sticky situation again. While applying the same tactics and skills they have already learned, they should also sit down with their financial advisor and make sure that they understand exactly how their scheme works and how much their medical savings for the year is and where they need to fund any co-payments. Once they have a better understanding, they should draw up a medical savings budget which includes all the medicines and vitamins they may require for the year and that they purchase on a regular basis. Once they have a total spend amount, consumers should then assess if they have anything left over for those unforeseen medical expenses. If they find there is little, or no savings left or that they will run out of medical savings before the year is up, they should seriously consider which items they could pay cash for in order to minimise their financial risk should they fall ill unexpectedly. Remembering that anything they don’t spend from their medical savings will carry over to the next year, putting them into an even better situation than before.

Get the best out of your medical aid

How to get the best out of your medical aid in a tough economy

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Increasing petrol, electricity, water and food prices, and salary increases that barely cover the cost of inflation leaves the average South African consumer under tremendous financial pressure to make ends meet each month. This is evident from the March 2018 Credit Bureau Monitor which shows an alarming number of Credit Active South African consumers (50.4%) that are in arrears on their accounts.

 

Is the cost of medical aid contributing to the financial pressure of consumers?

There is a worldwide phenomenon, where the high cost of medication and new medical technology is pushing up the cost of medical expenses for the average consumer. In October last year, Fin24 reported that the average year-on-year increase of medical scheme contributions over the last 16 years has been 7.6%. According to Alexander Forbes Health, this is 1.9% higher than CPI inflation. It should come as no surprise then when StatsSA reveals that only 9.5 million people in SA are covered by a medical aid and that public clinics are still the first point of contact for most South Africans, with only 24.6% of the population using private doctors when ill.

 

Having medical cover offers consumers peace of mind, but the monthly contributions might be too much for consumers to bear!

It’s no secret that South Africans are struggling to maintain their medical aid repayments and may in many instances be considering ways to reduce this monthly expense. This is a risky decision which warrants doing research into the options available and how to reduce costs while getting the best cover available within budget constraints. Consumers that are considering cutting their medical aid from their monthly budgets to maintain other financial obligations, must carefully evaluate their options. Here are some ways to reduce medical scheme contribution costs without cancelling cover altogether:

  1. Are there any other costs that can be cut?

    While this option may seem obvious, its often perceived by consumers that it’s easier to cancel a medical policy than to try to reduce other living expenses. Running a family budget is never easy as it requires buy-in and commitment from the whole family. Reducing unnecessary costs is preferable to losing your medical cover. As such, consumers should take a hard look at their situation and consider sacrificing some luxury items like private schooling, DSTV subscriptions, eating out and maybe even selling off a second car.

  2. Investigate dropping your medical cover to a cheaper option (like a hospital plan)

    The number of benefits consumers opt for will determine how much they pay. Consumers should therefore investigate more affordable options with reduced benefits that their current scheme offers. The bigger the scheme, the more options available. However, consumers that are part of smaller schemes will have a more limited choice and may need to look outside their current scheme for better deals. One of the key challenges with trying to downgrade to cheaper cover is that most schemes only allow members to change to a different option once a year, usually towards the end of the year. Therefore, consumers will need to plan carefully and allow enough time to do their research, so that they can make an informed decision within this specified period. This is not a decision to be rushed.Some of the more common downgrade options that can be considered include; dropping down to a cheaper option with limited out-of-hospital cover and/or a smaller medical savings plan or no savings plan at all. There are also options available whereby consumers pay less if they use providers that are listed as part of the scheme’s doctor network. When deciding to downgrade your cover, be mindful of your own and your family’s current and possible future needs. Find an option that has suitable cover and that fits your budget.

  3. Manage the dependents on your scheme

    If you have three children, there is no rule stating they all must be listed as dependents on your medical scheme. Most consumers don’t know this. While it may be risky, immediate savings could be made by removing healthy child dependents from your scheme and only keep those with greater medical needs covered. A better risk to take than to have no cover for the entire family. Should the main members financial situation improve, they could always add the other dependents back again. Just remember that there might be waiting periods imposed in this event.Another consideration is the cost of children that move from ‘child dependent’ status to ‘adult dependent’ status when they near the ages of 18-21 (depending on the scheme). As children change to adult dependents, their monthly contribution in some cases could double. Consumers in this situation should consider moving healthy adult children onto their own, more affordable hospital plan. Another option is to register your adult dependent as a student. As long as you have proof that your adult child is a full-time student with no income of their own, most schemes will allow for a discounted student rate. Also, some schemes only charge for three child dependents, so families with more than three children should definitely look at moving to one of these schemes.

All of these options are not as ideal as full comprehensive medical cover, and each comes with its own risks. However, the risks associated with these reduced cover options are still far better than the alternative of no cover at all.

Understanding how your medical benefits work is a daunting task for most consumers. For example, a scheme might cover a member for 100% of hospital costs at the medical fund rate. This doesn’t mean that all in-hospital costs will be covered, and uninformed consumers could still be left with an enormous bill for making use of a specialist that charges more than the medical fund rate.

Consumers wanting to explore how to get the most out of their medical aids in this tough economy should make use of the free instant online medical aid comparison tool available at medicalaid.co.za.

Medicalaid Information you need to know

Medical Aid – The Basics

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What are the basic principles of medical aid – how does it work?

South Africa has a dual healthcare system, consisting of public and private providers. Private hospitals are used mostly by members of medical schemes or those able to pay for these services out of their own pocket.

Medical aids are regulated by the Medical Schemes Act (1998). They are essentially non-profit organisations and belong to their members. Continue reading →

Medicalaid Benefits

Benefits, exclusions and limitations

Posted on By Daisy Ditshoene - Senior Analyst Council for Medical Schemes

Benefits can become complicated. For your own good, here’s what you should know.

Medical schemes undertake liability in return for a premium or contribution. They are required to help their members in obtaining healthcare services and defraying expenditure for such services. The benefits that a scheme may grant must be registered in its rules. Continue reading →

Choices

Important considerations when choosing a medical scheme

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Before choosing a medical scheme, and an option within that medical scheme, you need to consider the following points:

Needs and financial analysis

When deciding to join a medical scheme, first ask yourself what you can afford to spend on the monthly premium per month. Then look at your and your family’s needs. What is it that you need from your medical scheme? Continue reading →

How and why people join medical schemes

How and why people join medical schemes

Posted on By Patrick Matshidze - Council for Medical SchemesActing registrar of Medical Schemes and head: Research & Monitoring (until 30 November 2009)

Various factors enable groups of individuals to join medical schemes.

People need to understand the social solidarity nature of medical scheme cover.

Most South Africans join a medical scheme through their employment. Another reason why individuals join medical schemes is because they are seeking a perceived higher quality of care in the private sector, particularly for hospitalisation. Most people cannot afford to pay out-of-pocket for private hospitalisation, therefore they enrol in medical schemes.

There are people who join medical schemes purely because they are risk-averse, meaning that they are not compelled by their employer to do so but join because they understand the catastrophic nature of healthcare expenditure. Medical scheme cover gives these individuals access to better resourced healthcare facilities that would otherwise be beyond their reach. Continue reading →

PMBs and Chronic Diseases

PMBs and Chronic Diseases

Posted on Source: Council for Medical Schemes

What are PMBs?

Prescribed Minimum Benefits (PMB) is a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. The aim is to provide people with continuous care to improve their health and well-being and to make healthcare more affordable. Continue reading →

Understanding Medical Aid Tariffs

Understanding Medical Aid Tariff

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What does ‘100%, 150%, 200%, 300% and 400% of scheme tariff’ mean?

Medical aid quotes and brochures often state that the scheme will cover your in-hospital costs at 100% of the scheme tariff.

But surely 100% is, well, 100%? If you’re charged more than that, aren’t you supposed to get money back? Not necessarily in this case. Continue reading →