Reviewing your Medical Aid option

August 27, 2020

We are fast approaching medical scheme product update season, and there has been much speculation around what to expect for 2021 amidst the Covid-19 outbreak, and its impact on the private healthcare sector.

South African medical schemes have historically increased contributions well above inflation, with a weighted average of around 9-10% mark.

As the economy has taken strain, and many citizens are impacted financially, a review of expenses becomes critical, and insurance is usually at the top of the list.

Our evolving dual healthcare system still places membership to medical schemes as key to access quality private healthcare. A review of your current cover is prudent as it can help you understand if you are over-insured or under- insured, maximising your benefits, and what changes you can implement to possibly save on medical expenses overall.
We share some practical information that you can use to review your current cover.

Key Benefits

Hospitalisation
The fundamental reason members join a Medical Aid is to ensure cover for hospitalisation. Consumers know that the cost of private care hospitalisation can be exorbitant and often financially crippling without the right level of cover.
Most schemes offer unlimited cover for hospitalisation. There are still a few options with overall annual hospitalisation limits that are aimed at providing some level of cover for lower-income earners as opposed to no cover at all.

Schemes also provide options that impose restrictions on what hospital members may use for a planned admission. This allows them to charge a lower contribution. So, if this is your option, make sure that you are familiar with the hospitals on the list.

Day-to-Day
The new generation plans offer a Medical Savings account that caters for day-to-day expenses, subject to available funds. There are a few traditional model options on the market; however, they are generally highly-priced. Hybrid options offer a mix of benefits funded from medical savings and risk pools. The extent of day-to-day cover is where most of the variation occurs in terms of options available and can affect the overall contributions substantially.

Scheme Rate
This refers to the medical scheme’s rate of reimbursement for related accounts. Schemes can cover from one time, and up to three times, the medical rate, depending on the plan option.

Questions to consider

  • Are you comfortable with hospital restrictions for planned admissions?
  • Do you have a Gap Cover product?
  • What are 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? Are you accessing cover available from the schemes Chronic Benefit?
  • What routine checks and tests do you have done? Are you utilising the Screening Benefits available on your option?
  • 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, factoring in your specific healthcare needs in a comprehensive review with your financial adviser.


Article written by

Paramesh Dayaram

Head: Healthcare

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