Time to review your medical aid option

Spotlight on 2019 Healthcare Industry

South Africans eagerly, albeit with bated breath, await the proposed full implementation of NHI in 2026.

The debate on NHI, its roll-out and what relief this will bring to the cost and cover of healthcare for South Africans continues fiercely amongst stakeholders.

Those covered under private healthcare continue to experience premium increases well above inflation year-on-year.

The Council for Medical Schemes’ annual report has been released and their statistics mirror the findings of the Competition Commission’s Healthcare Market Inquiry, reflecting rising cost and expenditure in the private healthcare industry.

Statistics from the annual CMS report 2017/2018

• In 2018, the number of medical schemes declined to 79, comprising 21 open schemes and 58 restricted medical schemes.
• The report notes that there has been an increase of 0.18% in the number of beneficiaries between 2017 and 2018 on open medical schemes.
• The total healthcare expenditure on benefits paid in 2018 amounted to R173.3 billion, an increase of 8.0% from the 2017 amount reported.
• Out-of-pocket expenditure amounted to R32.9 billion in 2018, which represents 19% of the total benefits paid.

Reviewing your medical option as part of your budget

At this point in time, medical schemes will continue to operate as normal, which means that a review of your benefits and cover versus the cost is still a crucial component of your budgeting process.

Members automatically consider downgrading options when faced with premium increases.

This may be appropriate for some, but carefully consider if you are not merely decreasing contributions in lieu of restrictions not suited to medical needs and larger out-of-pocket expenses.

Questions to consider

• Are you comfortable with hospital restrictions for planned admissions?
• Do you have a Gap cover product?
• What is the total out-of-hospital expenses for everyone on the membership? Tip: use an average of the last three years.
• What chronic conditions do you require cover for?
• What routine checks and tests do you have done?
• Are there any upcoming expected treatments that you and your family require in the next twelve months?
• Can you afford to pay day-to-day expenses out of your own pocket?

Important Documents

To assist you with your review, you can request these documents from your provider:

• Claims Transaction History Statement
• Self-Payment Gap reconciliation report (if your plan has this component)
• Chronic Benefits Guidelines
• Screening Benefits Guidelines
• Plan Brochures

The most effective way to review your medical aid plan is to compare your plan option and benefits on a like-for-like basis against potential alternatives. Make sure you factor in your specific healthcare needs in a comprehensive review with your financial advisor.

You are welcome to contact us at Chartered Employee Benefits with any queries.

Paramesh Dayaram is a Senior Healthcare Consultant at Chartered Employee Benefits.