As medical schemes launch their annual contribution and benefit changes, the focus understandably turns to what the new year will cost.

For many scheme members, private healthcare represents a significant household expense. At the same time, it provides access to quality healthcare and financial protection, necessitating the purchase.

This makes a review of your healthcare benefits about more than comparing contribution increases. It is an opportunity to understand whether your current healthcare arrangements continue to meet your needs, which benefits are being utilised, and where you may have gaps in cover or unnecessary expenditure.

Here are five things to consider when reviewing your healthcare benefits.

1. Start with a review of your historic utilisation and healthcare needs

Your claims history provides a useful picture of how you and your dependants have used your medical scheme over the past few years. Rather than looking only at the total amount claimed, consider the types of healthcare services you have accessed and how these were funded.

For example, look at your use of general practitioners and specialist consultations, chronic medication and disease management, dentistry and optometry, diagnostic tests and imaging, in-hospital and day procedures.

It is equally important to consider what may change. A historical claims review is useful, but it cannot account for a new diagnosis, a planned procedure, changing family circumstances, or other healthcare needs that may arise during the next benefit year.

2. Understand your hospital and related accounts

Protection against the potentially high cost of hospitalisation and access to appropriate healthcare remain fundamental reasons for belonging to a medical scheme.

Most options provide unlimited hospital cover, but this does not necessarily mean that every cost associated with an admission will be covered in full. Network hospitals, designated service providers, pre-authorisation requirements, co-payments and reimbursement rates all affect the level of cover and the member’s potential financial liability for account shortfalls.

Before changing options, understand:

• Which hospitals are available for planned admissions and whether designated service providers apply;
• What co-payments and/or deductibles apply to the plan and when they apply;
• How specialist and other provider fees are reimbursed; and
• Benefits covered, limits, and authorisation requirements.

3. Look at how your day-to-day healthcare is funded

Day-to-day benefits in most benefit structures are largely funded through a Medical Savings Account model. There are options which provide risk-funded benefits, defined limits or a combination of funding mechanisms.

While downgrading to a hospital plan may reduce the monthly contribution, it may result in greater out-of-pocket expenditure, depending on your claiming patterns.

For some, the upfront allocation of a medical savings account is meaningful in their access to care, whilst others opt to carry the cost of their day-to-day expenses from their own pocket.

The important point is to understand the trade-off between annual contribution savings and additional costs that may arise from reduced benefits linked to your day-to-day benefit needs.

4. Review your Chronic, Preventative, Screening and PMB benefits

Medical schemes are placing a larger focus on preventative and screening benefits. These benefits should not be overlooked as they include health assessments, screening tests and other preventative interventions, depending on the option. Some medical schemes are incentivising members for participation by enhancing their day-to-day funding and access to benefits.

If you or a dependant has a chronic condition, check that the condition is correctly registered with the scheme and understand the requirements for accessing the relevant chronic benefits. This includes any treatment protocols, formularies or designated providers that apply.

Prescribed Minimum Benefits (PMBs) should also form part of this review. PMBs provide cover for a defined list of conditions and treatments, subject to the applicable requirements and managed-care protocols. Understanding how these benefits operate is particularly important where a member is managing a significant ongoing condition.

5. Consider your healthcare benefits as a complete picture

Finally, consider your healthcare benefits beyond the medical scheme itself. As South African medical schemes navigate the rising cost of healthcare, and members balance affordability, supplementary products such as gap cover should be a key consideration.

Gap cover provides cover for medical expense shortfalls for claims not fully covered by your medical scheme. Benefits can include cover for in-hospital shortfalls, co-payment cover and medical scheme contribution waivers.