Optimising Medical Scheme Benefits
The private healthcare industry is abuzz as medical schemes announce their benefit changes and premium increases for the upcoming year.
The Council for Medical Schemes (CMS) issued a guideline for schemes to limit their premium increases for 2025 to 4.4%, plus “reasonable utilisation estimates”. However, market trend indicates that medical scheme increases will continue to be influenced by medical inflation, resulting in substantially higher than Consumer Price Index (CPI) increases.
During this period, members are allowed to change their plan options for the upcoming year. With the current South African economic climate and increasing living expenses, it is understandable why affordability remains one of the important factors members consider when selecting a plan option.
South African medical scheme members need to be savvy in their approach when choosing an option and utilising their benefits. It is important to balance affordability with appropriate benefits, which requires members to stay informed about benefits.
In this article, we outline risk-funded benefits that are available to members to gain access to appropriate healthcare and optimise utilisation.
Understanding Risk-funded Medical Scheme Benefits:
Prescribed Minimum Benefits (PMB)
This benefit covers a defined basket of care for treatment defined as emergency medical conditions and a list of 271 medical conditions. It ensures that qualifying medical scheme members have access to specified healthcare services, regardless of the benefit option they have selected.
Certain qualifying treatments may require the utilisation of a healthcare provider contracted to the scheme, commonly referred to as a Designated Service Provider (DSP), to qualify for full cover through this benefit.
Chronic Illness Benefit
The Chronic Illness Benefit covers members for a defined list of 26 chronic conditions. You need to apply to have your medicine and treatment covered for your chronic condition. The cover through this benefit is subject to limits, medication formularies and a defined basket of care.
Oncology
The medical scheme requires confirmation of the cancer diagnosis from the treating oncologist. Utilisation of a DSP may be a requirement for accessing this benefit, depending on plan choice. Plan choice may also dictate the level of care, as cover varies in overall limits to PMB level, and can extend cover to include biological drugs and innovative treatment.
Preventative Care
The purpose of this benefit is to encourage medical scheme members to go for their health checks, as early detection of certain conditions can lead to prevention and/or positive treatment outcomes. However, the basket of tests covered tends to vary from one scheme to the other. Some of the common tests or screenings include glucose, blood pressure, cholesterol and HIV tests. These screenings are subject to utilising a DSP. Some additional vaccines and tests that are usually age-band related, such as Flu, HPV and childhood vaccinations, mammograms and prostate screenings, can also be accessed through this benefit.
Maternity Benefit
This benefit is plan-dependent; the medical scheme specifies the basket of care, which may include pre and postnatal consultations, scans, and pathology tests. Members are encouraged to contact their medical scheme upon confirmation of pregnancy to register and activate access to these benefits.
Additional Benefits
The below are subject to plan choice and medical scheme benefits:
- Emergency Room consultation – this is generally limited to a specified number of casualty visits; qualifying criteria may be age and event-specific.
- GP Consultations – additional in-person/virtual GP consultations once a member’s day-to-day benefit is exhausted, subject to consulting with a contracted DSP; this may vary based on scheme and plan choice.
- Women’s Health – contraceptives, bone density scans.
Managed Care Benefits
This may vary from one medical scheme to the other, have definitive clinical qualifying criteria, and the application is subject to approval.
- Back and Neck Management Programme
- Mental Health Programme
- Post-Hospitalisation Programme
Should a member feel aggrieved by a funding decision made by the scheme, they may lodge a dispute or complaint with the medical scheme.
Ex-gratia
The scheme will review medical expenses not covered through available benefits or scheme rules, together with the case facts submitted through this application process.
A decision will be made on a case-by-case basis, where the scheme believes there are exceptional circumstances which warrant funding. This is not a medical scheme benefit, but it is classified as a discretionary fund where decisions by the scheme are final and cannot be disputed or appealed.
Take time to understand your benefits.
An authorisation or approval of a benefit does not guarantee that claims will be paid in full. Benefits may have limits, sub-limits, co-payments, require the use of DSP, and be subject to clinical entry criteria.
We acknowledge that scheme benefits and application processes may seem complex and challenging to navigate. Healthcare intermediaries serve as an excellent resource to facilitate and guide members through any hurdles they may encounter. For members, the benefit of taking the time to understand their cover better can save them from unexpected expenses.
When in doubt about a benefit, it is always best to contact your healthcare intermediary or scheme directly.
