Understanding your medical benefits during ‘open season’

Picture: Pixabay

Picture: Pixabay

Published Oct 12, 2021


By Kerry Vermeulen

SOUTH Africa is entering medical aid ‘open season’, where members can change their options. It is opportune to consider your requirements and benefits, rather than simply remain on the same plan for lack of an in-depth understanding.

Many medical aid members find it hard to understand their benefits and how best to use them. Terminology can be confusing and trying to compare options and schemes can be virtually impossible. Knowing more about how schemes operate could help you make an informed choice about which option is most appropriate for you and your family.

You’re already paying for advice

Did you know that whether or not you use a healthcare broker to advise you on your medical aid matters, you are probably paying for one if your scheme pays broker/adviser commission? Their fees are incorporated into most medical aid premiums and you do not get a discounted premium if you do not use a broker. It therefore makes sense to take full advantage of a healthcare broker’s advice and assistance.

A good healthcare adviser can advise you on:

  • a suitable benefit option offered by one of the country’s open medical schemes.
  • gap cover.
  • primary care.
  • occupational health.
  • healthcare insurance-type products.

Many people do not realise what benefits they have actually bought and are upset to realise during the year that they do not have enough cover.

A good healthcare adviser will help:

  • assess your use of medical aid benefits past and present.
  • determine your anticipated future needs.
  • guide you to the most appropriate option within your chosen medical scheme.
  • simplify the complicated terminology and scheme processes.

A healthcare adviser will guide members to make the most of the available benefits.

A member taking chronic medication may forget to register on the medical scheme’s chronic programme, meaning that the medication is paid for from savings or day-to-day benefits rather than fully covered by the medical scheme. In addition, by registering on the chronic programme, members may have access to additional benefits such as doctor consultations. A good healthcare adviser will highlight this fact to the member and save them money.

A highly regulated industry

The Medical Schemes Act of 1998 regulates medical aids. The Council for Medical Schemes has a responsibility to ensure compliance with the act. Should you have a dispute with your medical aid, the Council for Medical Schemes would rule on this.

What are medical scheme options?

Medical schemes have a number of options which 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 the network could mean that you have to pay in for the bill. You are allowed to change your selected option once a year, usually in January.

Hospitalisation cover

Some options require you to use specific hospitals for planned treatment. 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. However, beware – the authorisation will only cover at the scheme rate of payment but many providers who treat you in hospital such as specialists and anaesthetists may charge above this payment. This bill then becomes your responsibility. Be sure to check before your procedure what the treating specialists and anaesthetist charge. If a quote is obtained, your scheme will usually be able to tell you up front what will be paid.

Out-of-hospital cover

Some options cover day-to-day benefits (such as GP visits, optical benefits or medication) using a savings account, or in some cases a set scheme benefit. Always ensure that you are aware of what benefits and amounts are available to you, as well as the rate being charged – failure to do this may result in a co-payment where you have to pay up front from your own pocket.

Prescribed minimum benefit claims

The Medical Schemes Act sets out certain prescribed minimum benefits (PMBs) which all schemes have to pay for, regardless of which option you are on. The PMBs are a list of all of the conditions which all medical schemes need to cover on all the health plans they offer to their members. This cover includes funding for the diagnosis, treatment and ongoing care for the listed conditions. According to the Medical Schemes Act and its regulations, all medical schemes have to cover the costs related to the diagnosis, treatment and care of a defined set of 270 diagnoses and 27 chronic conditions.

It is important that you review the PMBs if you suffer from any condition or expect to have any treatment. Each scheme is entitled to apply their own rules to treatment of the PMBs and members should take advice on claiming for these.

Chronic conditions

Chronic conditions are potentially life-threatening conditions where ongoing medication is required. The scheme must cover 25 chronic conditions within set guidelines as prescribed minimum benefits. The more common chronic conditions include asthma, high cholesterol, high blood pressure and diabetes. In these instances, the scheme will have to pay for certain medications as well as certain treatment, which may include blood tests and doctor visits. It is important to register for these conditions, as they will then not affect your other day-to-day benefits. The scheme may only pay certain medication amounts or for specific medications, so you should try to get your doctor to prescribe these so that you do not have a co-payment.

Rates of payment

Many members believe that their medical scheme will cover the full cost of what the doctor charges. They 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. Beware of misunderstanding the often-used ‘100% of scheme tariff or rate’. This does not mean that your healthcare provider will be paid in full, as they may charge substantially more than this scheme rate. Negotiate with your doctor to ensure that you are getting the best possible rate.

Health cover comes at an ever-increasing cost. Review your plan every year to ensure that it is meeting your needs.

Kerry Vermeulen is a healthcare adviser at Alexander Forbes Health.


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