There is quite some noise in the media and industry about changes and challenges in the medical scheme industry. Medical scheme members feel overwhelmed and worried that even though they are paying huge monthly premiums, they are getting the short end of the stick.
You can, however, get your money’s worth and have peace of mind when it comes to you and your dependents’ healthcare needs.
The key is to understand the product and benefits offered and staying on top of the latest regulation, medical scheme rules and new industry information. Or, even better, have a health cover specialist that does that for you.
The burning issues which most medical scheme members struggle with, include the ever-increasing premiums, not knowing what the scheme will cover and how to avoid out-of-pocket expenses that occur due to shortfalls or co-payments.
The right medical scheme for your healthcare needs and budget
With medical scheme premiums that have become one of our biggest monthly expenses, it is really important to ensure you continue to have access (and cover) to high quality healthcare that fits your specific needs.
It’s important to familiarise yourself with the other options available and compare your current health cover portfolio with alternatives. The same medical scheme option that you have been on for the last couple of years might not offer the type of benefits you (or your dependents) now need. Should your financial situation change for whatever reason, you might need to find an option or a new scheme that might be more affordable while still giving you sufficient health cover.
Getting the comparison is one thing, but it be can be quite daunting to understand the content and to determine which medical scheme or option will serve your needs the best. This is where your medical scheme specialist plays an important role. Your best medical scheme broker is one that can give you in-depth, but also independent insight into all the big medical schemes available in the market.
Understand your benefits and save money
If you are a member of a registered medical scheme in South Africa, you get automatic cover for the 270 illnesses and diseases that are listed as Prescribed Minimum Benefits. Even if you are only on the most basic hospital plan, PMB cover applies.
Be wary of short-term insurance products such as hospital cash back plans that market health cover at very low monthly premiums. These products are not registered medical schemes and do not give you access to PMB cover or the full hospital benefits which a medical scheme would. New legislation is also going into effect this year which will have products either restructuring their offer or they will be discontinued, leaving the policyholders without any health cover.
Other ways to ensure you manage your medical scheme cleverly and save money is to understand and use the contracted networks and designated service providers linked to your scheme and option. Most medical schemes and options have a list of medical service providers which the members can use without paying co-payments or penalties.
Your medical scheme broker can assist you with PMB claims and to determine which hospital and doctor is on your scheme’s network – ensuring you utilise your benefits without having extra expenses. That also includes registering your chronic medication as per the schemes’ formulary correctly and tightly managing your day-to-day savings component.
To cover the gap or not…
Medical scheme brokers that are worth their weight in gold will know the medical schemes and different options well enough to help you establish if you would benefit from a gap cover policy.
And most medical scheme members would. Remember, doctors and specialists can charge up to 500% more for in-hospital procedures than what the medical scheme tariff is for planned hospital procedures, leaving you with the shortfall (gap) amount.
Adding to that, medical schemes impose co-payments on scans and other listed in- and out-of-hospital procedures. Those co-payments are from the members’ own account.
There are gap and co-pay cover policies (stand alone or combined) available that could cover these expenses, ultimately optimising your full health cover portfolio.