Choosing Affordable Medical Aid
GERHARD VAN EMMENIS, acting principal officer Bonitas Medical Fund says, because the medical aid landscape can be tricky to navigate, it is important to compare all available options and schemes to find a medical aid that works for a family’s health and is within its budget.
“This.” He adds, “applies whether one is making that choice through the open market or an employer.”
If one is already on a medical aid he strongly advocates establishing the family’s typical health care costs in the previous 12 months:
How much was spent on day-today healthcare expenses? Was anyone admitted to hospital? Was a specialist visited regularly? How often was a GP consulted? Does anyone in the family have a chronic condition? How much was spent on dentistry, optometry and over-the-counter medicine? Were day-to-day benefits and/or savings exhausted? What was the level of co-payments and/or deductibles? “Then”, he says, “consider which of the expenses listed above were once-off, such as childbirth, and which are likely to come up repeatedly, such as flu. Also take the time to read the information sent to you by the scheme and/or your broker to ensure you understand what it is offering so that you can make an informed decision.”
Because the cost containment measures medical schemes apply for day-to-day benefits are often broad, he says it is important to investigate, or bear in mind, the following:
If the medical aid contracts with hospitals, doctors and specialists are you willing to use them and are they close by? Using contracted or network providers usually means obtaining full or improved cover levels. It also helps ensure you are getting more value for money as doctors on your medical scheme’s network will not charge more than the rate agreed with your medical scheme.
Must you be referred to a specialist by your GP?
Does your medical aid offer additional GP consultations, which they will pay for, after you have exhausted your day-to-day benefits?
Does your medical scheme offer any additional benefits such as managed care programmes or maternity, preventative care or wellness benefits that are paid from risk and not savings or day-to-day benefits?
To get more value for money one should use generic medication wherever possible and try to keep claims within any specified sub-limits.
Find out if your option has any day-to-day benefits that are paid by the scheme from risk (not from your day-to-day sub-limits or savings)
“Using network doctors is an invaluable tool to make medical aid last longer. It means they, can't charge you more than a specific amount,” he reveals.
Presently, Bonitas has the largest GP network.
Addressing additional benefits, van Emmenis recommends ask what supplementary benefits are available that can potentially save significant day-to-day expenses.
These could include: preventative care benefits, ranging from basic screenings (blood pressure, cholesterol, blood sugar and body mass index measurements) through to mammograms, pap smears, prostrate testing.
In some cases this extends to maternity programmes, dental check-ups, flu vaccinations and more.
These usually require authorisation from the scheme, failing which they are simply met from your day-to-day benefit limits.
Age is a factor. As he says, “If you have young children, ensure that the medical aid option you select provides sufficient child illness benefits.
“However, if you are slightly older, then check that the option you select covers chronic conditions and provides sufficient in-hospital cover.
“Also keep an eye out for programmes that help you to manage chronic conditions such as diabetes and cancer.”
When comparing the different medical aid options available, consider all the costs involved, including the affordability of the monthly contributions as well as the cost of co-payments for various benefits claimed.
A medical aid co-payment is a fee that the member is liable for when making use of certain medical services.
The medical aid does not cover 100 percent of the costs and the member has to pay for a certain percentage of the medical service before the medical aid pays its portion.
These co-payments usually apply to specialist or elective medical procedures and differ from one medical aid scheme to another.
“It is,” he adds, “one of the reasons why you should always do thorough research before deciding which medical aid scheme is the best option for you.”
SOME ADDITIONAL ADVICE
How good is the payment record? Phone your GP's receptionist and find out whether they have experienced problems with pay-outs from that particular scheme.
Check a scheme's solvency ratio. According to the law, schemes should have at least 25 percent of members' annual contributions in reserve.
Scrutinise the table of benefits. Things may look good on paper but check what the day-today limits are and how much your Medical Savings Account is per year. If small, you could exhaust your day-to-day cover quickly. Also remember that many private hospitals don’t charge medical scheme rates so check what co-payments you will have to make on all bills.
Any waiting period or exclusions? Schemes may impose certain waiting periods for new members when joining or for a pre-existing medical condition. This is based on the guidelines of the Medical Schemes Act and the specific scheme’s rules. Bonitas recommends that you enquire with the relevant scheme about their exclusion list and waiting periods.
He concludes, “Don’t forget that you do have the option to use an independent broker who will help you choose the medical aid plan best suited to your and your family’s needs.”