Members are usually required to notify the scheme beforehand for planned hospitalisation and are provided with an “authorisation number” confirming that the procedure will be covered at the option rate. File Photo: IOL
JOHANNESBURG – Many medical scheme members find it hard to understand their benefits and how best to use them. For this reason, trying to compare options and schemes can be virtually impossible for the layman. Knowing a little more about how schemes operate could help you make an informed choice about which option is most appropriate for you and your family.

Coastal head of healthcare for Alexander Forbes Health, Victor Crouser, said the terminology used in medical scheme brochures was often confusing. Crouser offers the following tips:

Medical schemes are regulated by the Medical Schemes Act of 1998 and the Council for Medical Schemes has a responsibility to ensure compliance with the act. The council’s website is and one can find useful information regarding the legal aspects and management of medical schemes. The council also rules on disputes between members and their medical schemes.

Each medical scheme must have a board of trustees who manage and control the scheme’s affairs, complete with a set of rules which members are entitled to a copy of. As a member you are entitled to attend the annual general meeting of the scheme and you can vote for trustees.

Medical schemes have a number of different options and these differ according to the benefits on offer and the contribution payable. Contributions may vary according to family size and make-up, as well as income. It is important to know if your option requires you to use certain providers, as using a doctor or provider outside of the network could result in you having to pay in for the bill. You are allowed to change your selected option on a yearly basis, usually in January.

Planned hospitalisation

Some options require you to only use specific hospitals for planned treatment and this cover may pay at certain rates or have an overall limit. Members are usually required to notify the scheme beforehand for planned hospitalisation and are provided with an “authorisation number” confirming that the procedure will be covered at the option rate.

Day-to-day benefits (such as GP visits, optical benefits or medication) are covered by some options. These may be covered by a savings account, or in some cases by a set scheme benefit.

The act sets out certain Prescribed Minimum Benefits (PMBs), which all schemes have to pay for, regardless of which option you are on. These PMBs cover various serious conditions and it is important that you review them if you suffer from any condition or expect to have any treatment.

Chronic conditions are usually described in layman’s terms as potentially life-threatening conditions where ongoing medication is required. The PMBs set out 25 chronic conditions that must be covered by the scheme within set guidelines. It is also important to know that the scheme may only pay certain amounts or for specific medications so you should try to get your doctor to prescribe these so that you don’t have a co-payment.

Many members believe that their medical scheme should cover the full cost of what the doctor charges and are often shocked to find out that this is not the case. Providers are allowed to charge at different rates, but the scheme option that you are on will pay only at a specified rate.

Many healthcare providers are reasonable and are prepared to negotiate their charges upfront if members are open and honest. However, they are naturally reluctant to do so when members come to them later, once they have found out that the scheme has not covered the full bill. It is therefore better to discuss the financial situation with your provider upfront, even though this may make you feel slightly uncomfortable.

Ensure that your health cover is appropriate and adequate for your changing needs as you journey through the life stages. It is a good idea to use the services of an independent specialist health-care adviser or broker who has knowledge on various health-care solutions, such as medical schemes, gap products and other health-care products.