What type of medical scheme cover is right for you?
The evolution of the medical scheme industry within South Africa has resulted in a dizzying array of choice for individual healthcare consumers as well as for corporates looking to provide for their employees’ health needs.
“New generation options were introduced to offer a savings component separate from the collective risk pool of a particular medical scheme, while still offering structured access to specific categories of benefits, alongside traditional benefit options,” says Bianca Viljoen, spokesperson for Health Squared Medical Scheme, which was recently launched following the merger of Resolution Health and Spectramed medical schemes late last year.
“Add to this the hybrid model benefit options, which combine aspects of the traditional and new generation plans, that are now available on the market providing a wealth of choice for members.
“The three different types of benefit options have opened a kaleidoscopic range of choice, however, one needs to understand their own needs and priorities, and have a grasp of the type of cover each kind of benefit option provides in order to make an informed decision regarding healthcare cover.”
Traditional benefit options offer members structured access to healthcare in the form of a capped rand value across various categories of out-of-hospital services and unlimited access to in-hospital care at private hospitals.
“Traditional options offer exceptional rand value with access to both in- and out-of-hospital health cover. This means that if a member requires dental work to the upper limit offered on their chosen benefit option, it does not impact their entitlement to access cover for other categories of services, such as specialist consultations or radiology for example.
“These options offer great peace of mind and, hypothetically, if a member on a traditional option were to require care across all the categories of services available, they would be able to claim significantly more value than they contributed in a single year. However, the remaining benefits do not roll over to accumulate for the following year, but rather are replenished annually.”
New generation options
A second type of medical scheme cover is offered through so-called ‘new generation’ options, which provide the security of structured access to in- and out-of-hospital benefits complemented with a personal medical savings account (PMSA), whereby a portion of contributions are isolated from the risk pool and can only be accessed by the member.
“Our Millennium and Millennium Select options are proving particularly popular among larger and more established families. A great advantage of these Health Squared plans is that families only pay for two child dependants, as we provide free cover for the third child, as well as subsequent children.”
The difference between these two variants of the benefit option is that Millennium Select is an efficiency discounted option, which provides more affordable cover to the same benefits for members who are willing to make use of the scheme’s extensive designated healthcare provider networks.
“These options offer flexibility through the generous savings account allocation and above threshold benefits to cover the family’s day-to-day healthcare needs. Our members appreciate the unlimited access to oncology benefits, subject to Independent Clinical Oncology Network [ICON] protocols and option-specific medicine formularies, as well as cover for 59 chronic conditions, including attention deficit hyperactivity disorder [ADHD], and advanced dentistry available on the Millennium options.”
While the structured benefits are granted on an annual basis, as is the case with traditional benefit options, any remaining savings in the PMSA component of such plans are accrued year-on-year.
Hybrid benefit options
According to Viljoen, hybrid benefit options represent the “best of both worlds” as they combine the structure of traditional benefit options with the flexibility of new generation options to deliver exceptional value for members who are looking for greater freedom in terms of cover for their day-to-day healthcare needs.
“Hybrid options are particularly well suited to large families who are looking for the security of comprehensive structured in-hospital cover but wish to keep their out-of-hospital cover fluid so that they are not limited in terms of access to the different categories of care.
“If a member needs a considerable amount of advanced dentistry work, which may exceed the amount of cover available for such services in a mid-range traditional option, but has no occasion to make use of medical specialist consultations and the various other categories of benefits in the year, then a hybrid option may well be ideal for them.”
This is due to the freedom of choice these options provide for members to allocate their PMSA funds to whichever out-of-hospital services they require, limited only to the amount available in their savings.
“The range of options available means that Health Squared really does have members covered from every angle. These products can also be seamlessly integrated with the Agility HealthPocket for individuals or Agility Corporate for businesses, allowing consumers to build their own health cover to suit their requirements.
“For those making use of this composite solution, any qualifying shortfall that may otherwise result in co-payments for members when they submit a claim is automatically directed to claim from Gap Cover so that the member is not required to pay out of their pockets unnecessarily, while our systems take care of the paperwork on their behalf.
“With the breadth of healthcare cover available, there is a Health Squared solution to suit every need. Understanding the structural elements of each type of benefit option is key to deciding which type of cover is best suited to your family or business’s health requirements,” Viljoen concludes.