It’s time again to make difficult decisions about your medical aid scheme. Traditionally in September and October schemes launch their new product plans and announce the revised benefits and premium contributions.
And while it may be an information overload for some, knowledge is definitely power when choosing the right scheme and cover
option for you and your loved ones.
Discovering certain procedures aren’t covered or that there are long waiting periods for chronic condition cover are some of the unpleasant shocks that unwary members can expect.
With over 80 schemes in SA, choosing the right one can be a daunting and confusing task.
We spoke to experts in the field about what to keep in mind when considering a new medical aid.
Mark Arnold, principal officer of Resolution Health said: “People who are joining a medical scheme for the first time and are not certain what their chosen benefit option entitles them to are at risk of either not making full use of their benefits or discovering that they do not have adequate cover for their health care needs when they need it most.”
A fundamental aspect in understanding how medical schemes work is that, by law, schemes must operate as not-for-profit entities.
Arnold said open-enrolment schemes are legally obliged to accept all persons who apply for membership.
“This leaves schemes and their existing members open to potential abuse by individuals who only join them when they become aware of a condition that requires medical treatment.
The Medical Schemes Act has therefore incorporated a provision that allows medical schemes to impose a waiting period.
Waiting periods are applicable to people who have never belonged to a scheme before, or individuals who have not belonged to a scheme for an extended period of time.”
During this period, the new member cannot claim any benefits, except for prescribed minimum benefits.
Gerhard Van Emmenis, principal officer of Bonitas, said diligence and some homework was required before choosing a medical aid.
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.
* Does anyone have a chronic condition or need to see a specialist?
* How much do you 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 health care, 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,” Van Emmenis said.
The Board of Healthcare Funders of South Africa cautions members to be careful when choosing benefits:
* If you change schemes, you might suddenly find yourself having to pay adult rates for your child who is studying at university. Or, if the specialist you’ve been seeing for the past 10 years is not on the new scheme’s list and you want to continue the doctor, you may have to pay for this yourself, especially if he or she charges more than your benefit tariff.
* Never assume that the benefits under the new scheme may be the same as your current medical aid.
* Some schemes allow you to keep your student children registered as dependants up to the age of 25 while others cut-off at 21 or 23.
* Optical benefits on some medical aids allow for a new pair of prescription reading glasses every year, while others only provide this benefit every second year.
* Some schemes will only pay for a medical specialist after you’ve seen a GP first and have a referral to the specialist.
* Some medical aids restrict the number of specialist visits you have in a year while others restrict which specialists you use by means of a list of designated providers or participating providers.