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Tips to make your medical aid work for you in 2020  

Begin by understanding the components of your cover.

Choosing an appropriate medical aid scheme can be overwhelming and while the country is experiencing a grim economic period, tightening your belt is essential. However, cancelling your medical aid should be avoided as this cover will protect you financially if you have unexpected medical emergencies.  Rather look at how you can make your medical aid and savings last longer.

In difficult times, the first thing many people do is look for a more ‘budget friendly’ plan – usually the most alluring is a health insurance plan, however, it is important to note that while health insurance may cover unforeseen medical aid care, it is not as extensive as medical aid cover and may not cover the Prescribed Minimum Benefits, which are covered on all medical schemes. 

Primary health care insurance cover is also available to cover healthcare expenses and is designed to offer affordable primary health care cover to the previously uncovered population. It should be noted that these products often do not cover all hospitalisation and they are not necessarily a viable substitute to a medical aid scheme. 

Gap cover is a separate type of healthcare insurance cover and is designed to cover certain medical costs that your medical aid may not cover while you are in hospital. It is also important to understand that these products are not medical schemes and can only be offered in addition to valid medical scheme membership. Cover will depend on the particular product and depending on design, may not include:

  • Co-payments for procedures when you are in a waiting period
  • Routine medical check-ups and out of hospital visits
  • Home based care
  • Medical procedures that are done by non-network medical service providers

Gap cover could however cover:

  • Some of your casualty unit costs
  • Co-payments for certain specified hospital procedures
  • Cancer treatment co-payments to an extent

The yearly increase on medical aid cover can stretch your budget as premiums increase, but make your medical aid go further by doing the following: using network doctors, optometrists, hospitals, dentists and network approved pharmacies. Visiting your General Practitioner first instead of going directly to a specialist, utilising medication which forms part of your scheme’s medicine list or formulary to avoid co-payments.

Generic medication can also dramatically reduce your spend on medication, so ask your pharmacist for advice when filling prescriptions.

The best way to make your medical aid go further is by understanding how various benefits and components of your medical aid work and what they cover.

Speaking to a health care advisor is the best possible way to ensure you get the very best out of your cover, as they can advise on your individual needs when choosing a plan which can ultimately save you in the long run. No two individuals are alike and therefore what they require out of a medical aid plan would differ, so consult a professional about cover that suits your personal budget.

Annelé Oosthuizen, senior consulting manager at Alexander Forbes Health.

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COMMENTS   15

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These types of articles are insanely stupid and naïve. I have had the self same doctor (general practitioner) for 40 years, as has the rest of my family why would I want to go out and find a new doctor functioning under some or other pre- determined network doctor. Maybe Alexander Forbes is a strong supporter of the patient conditions at all state hospitals and then again the fees levied by medical aids is quite eye – wateringly expensive – there are no financially challenged medical aids they are all awash with capital

And not to forget those “availability or facility fees” which the DSP’s charge in cahoots with one’s medical aid and paid to the service provider in December 2019 irrespective whether it was a normal working day, devoid of weekends and public holidays!! Medicross is a major culprit and in the forefront of ripping medical aid members off in this regard!!!

Facility fees are an inevitable part of the structure of our private system where doctors are self-employed and charge for their services (in other words, the hospital can’t issue a bundled bill for emergency care). The hospital has to charge for having available nurses, pathology services and resuscitation equipment. These are not charities and if you want world-class private emergency care to be on standby when you need it, then you need to pay for it.

It’s not unreasonable advice to suggest that, if stretching your benefits as far as possible is your priority, you first consider network providers, who agree to charge a lower rate to the insurer in exchange for the patient volumes. If your priority is seeing your own trusted doctor, rather than keeping your out-of-pocket costs down, that’s fine. But, for a lot of people, that’s a luxury and what they need is affordable, accessible primary care.

Strange that you agree to service providers charging facility fees when one makes an appointment a day or two in advance with a health care provider operating a practice out of places like Medicross, Lifemed, etc. I think they refer to these cretins as Snake Oil Salesmen, where integrity is of no value!!!!

please explain facility fees. i am at Medicross and I do pay extra for a weekend consultation. Is this what you mean?

A facility fee is levied by the hospital or health centre to cover the costs of running the unit (staffing, equipment, other operating costs). The doctors, who are invariably self-employed, invoice for their time. In some cases, there is indeed a steep surcharge by doctors for emergency work or emergency call-outs. This reflects the increased risk and workload arising out of complex emergency work; they impose surcharges for operating on very obese people for the same reason. There is no blanket policy, as far as I am aware, as to whether hospitals vary their facility fees according to whether treatment occurs during office hours or not. In all but the most dire emergency, it is essential to work out who is going to charge what before you agree to treatment.

The view that one should visit a GP before a specialist is a simplistic one. For anything more complicated than a headache or flu the GP is likely to refer the customer to a specialist willy-nilly, thus the hapless former individual ends up paying two doctor’s bills instead of one. I personally avoid GPs in favour of specialists – although I admit my preference is to stay clear of both.

It’s generally wasteful for patients to self-refer to specialists. GPs are able to provide first-line treatment for most conditions, and have the judgement to know when an immediate onward referral for specialist care or investigation is needed.

The reason why GPs are “able to provide first-line treatment for most conditions” is because most symptoms clear up within a week or so even without treatment – as I’m sure you know. As I only resort to professional medical attention in extremis, a GP isn’t likely to help me very much.

In the last year 82% of my medical expenses were self funded, more if you add in the savings account expenditure.

Why do we have this vastly complex scheme when it actually only really covers a few days that we may spend in hospital?

Medical Aid cover has effectively become catastrophe cover only. It covers you if you need to be admitted to hospital, or are diagnosed with cancer or many chronic conditions, but it really doesn’t cover day-to-day outpatient treatment. It’s not true or fair to say it only covers a few days in hospital – if you develop cancer, or diabetes, or suffer a stroke or serious injuries in a car accident, the scheme will shoulder all of the costs (subject to using their network, if you were able to make the choice at the time of the treatment, and subject to the treatment being evidence-based and in line with general practice for the condition at hand). They will treat your cancer (for as long as it is considered “treatable”…) in full, whether in or out of hospital, but they won’t pay for an extremely expensive new drug that has unproven potential to extend life by a few months. Healthcare is rationed everywhere in the world, whether in private or public systems and our Medical Aid system does this imperfectly – like any such system.

So what do you advise? A Very low plan which covers PMB conditions and hospital and the self funding of day to day expenses? But I am told that for inexplicable reasons service providers charge cash customers more than medical aid customers, unless of course they are on a top plan.

I have read the comments and detect enormous frustration and anger at Medical Aids. I have been a Member of Discovery for 15 years and my relation with the Scheme has been peaceful. I was however stunned last year to find the I had paid an enormous amount of momey to the MA, an amount of R5400 pe rmonth or (R64800 for the year) plus our of pocket expenses which came to R14000 for the year. The latter is for medical services and prescriptions only, I do not go outside this. Well the increases this year were very upsetting and I tried to downgrade but finding a plan with a reasonable spending account is impossible. I, however, downgraded to Delta Comprehensive from Classic comprehensive for a saving of about R6500 per year. By the way I even asked for a pensioner discount, I am 73, but to no avail!
Anyway this is my story. Please I have tried to contact Discovery, but have had no reasonable reply and Burger Radiologists, the other party involved but no luck. I went for a doppler test last week for one leg and an amount of R2362.70 was deducted from MSA. My partner went for a doppler for two legs mid December and R1865.40 was deducted from his Fedhealth account. Burger employee told me that I had been charged the Discovery rate and my partner the Fedhealth rate. How come Discovery is so much more expensive? There has been no price increase and the doppler in both instances was from the groin down. Also to pay more for one leg than two is totally inconceivable.
When speaking to a Discovery employee I was told that the higher plans pay more for doctors etc than the lower plans. I was also told that suppliers make their own prices and exactly the opposite was conveyed to me by Burger.
I have really tried to get through to a Manager at Discovery, but to no avail. If it is so as per Discovery employee about higher rates for more expensive plans then I need to examine my plans.

To add to my story, re the difference in rates for dopplers. Surely you pay for a service and that should be universal.

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