Medical Schemes
Medical aid scheme cover remains the number one insurance vehicle for accessing comprehensive private healthcare in South Africa. However, for many South Africans, medical aids are becoming increasingly unaffordable. This is reflected by the increasing number of existing scheme members downgrading their plans to more cost-effective options, and the scheme membership beneficiaries remaining stagnant for the last four years, with only 14.9% of the country’s population being insured.
The public sector currently provides healthcare for 85% of the population and accounts for approximately 48% of total healthcare spending. We cannot deny that NHI will play a major role in addressing this inequality. South Africans wait with bated breath for the full implementation of NHI and the positive changes it will bring to the healthcare industry.
Simphiwe Mofokeng, Senior Healthcare Consultant, looks at alternative options available to South Africans who wish to access private healthcare.
Covering Hospital Expenses
Health Insurance
Health Insurance policies are often perceived as a more affordable alternative to covering medical expenses when compared to Medical Schemes. However, the lower premium is representative of the limited cover provided. These policies may cover defined emergency hospitalisation stabilisation or illness, up to a specified rand value amount. This means one would not be covered for planned or non-emergency admissions through this type of policy. Health insurance cover should not be used in replacement of Medical Scheme cover.
Payment of a claim is usually made directly to the insured person and not the healthcare service provider. An example of this would be for accident treatment, a person may be insured for up to R150 000 per insured event with an excess of R600 being applicable. This type of policy is governed by the Long-Term or Short-Term Insurance Act; therefore the underwriting criteria and legislation differs from that of medical schemes.
Covering Day-to-Day Medical Expenses
Through Health Insurance policies, insured persons may claim for GP consultations, blood tests, x-rays, dental, optical, medication, etc. and the settlement of these claims may be made directly to the contracted healthcare service provider. Some health insurance policies cover chronic condition management; however, the conditions are specified and subject to a defined chronic medicine list. Oncology treatment is excluded.
Telemedicine
Recently we have witnessed a spike in the utilisation of telemedicine services – which provides healthcare services through virtual consultations. Modern technology has enabled doctors to consult patients by using telephonic and video conferencing tools. These consultations tend to be cheaper when compared to face-to-face consultations.
Prepaid Vouchers and Prepaid Card Systems
South Africa has entered the prepaid vouchers or prepaid medical cards system. Through these platforms, individuals will be able to purchase a voucher or load a rand value amount on the medical card which will enable them to consult and purchase medication through contracted healthcare service providers. However, some service providers such Discovery Health and Netcare Plus have been instructed by the Council of Medical Scheme to cease conducting the business of a medical scheme without the requisite approval from the CMS, Discovery has since appealed this decision by CMS, we await further updates in this regard.
If one cannot afford comprehensive medical cover, it is important when considering other forms of medical insurance to:
- identify the risk they want to be insured against and ensure that the policy of choice meets that specific need
- understand the exclusions, limits, co-payments applicable to that policy
It remains to be seen whether these new healthcare services will appeal to the needs of the uninsured South African population. While these products provide an entry access point to private healthcare, comprehensive cover remains limited to medical scheme cover.