Med­i­cal aid a case of Hob­son’s choice

CityPress - - Business - MOYAGABO MAAKE moyagabo.maake@city­press.co.za graphic). see

Choos­ing a med­i­cal aid plan can be daunt­ing, with 87 reg­is­tered med­i­cal schemes of­fer­ing hun­dreds of op­tions and no way to re­li­ably com­pare them.

What makes mat­ters worse is the fact that money is tight and med­i­cal aid providers con­stantly raise pre­mi­ums at more than the in­fla­tion rate ev­ery year.

“If you give con­sumers more than 102 plans to choose from, they will make a mis­take,” says Jill Larkan, head of health­care con­sult­ing at GTC (for­merly Grant Thorn­ton Cap­i­tal).

GTC re­leased its med­i­cal aid sur­vey this week, which an­a­lysed the dif­fer­ent plans of­fered by each open med­i­cal scheme in terms of the cost and cover of­fered.

Com­mu­nity Med­i­cal Aid, Med­imed, Selfmed and Thebe­med were not in­cluded in the sur­vey as they had not up­dated their benefits and rates for this year at the time the sur­vey was con­ducted. KeyHealth was also ex­cluded.

This showed that, de­spite be­ing the coun­try’s largest open med­i­cal scheme, Dis­cov­ery only had one plan that of­fered value for money and this re­stricted mem­bers to a con­tracted net­work of hos­pi­tals.

The pro­lif­er­a­tion of med­i­cal gap cover – which is now of­fered by blue chips like San­lam, Old Mu­tual and Lib­erty – af­ter the Na­tional Trea­sury pub­lished rules reg­u­lat­ing its pro­vi­sions last year, prompted GTC to dis­pense of its prac­tice to stan­dard­ise in-hos­pi­tal benefits by as­sum­ing all plans had 500% cover for hos­pi­tal ex­penses.

Some schemes only cover 100% of their tar­iffs for hos­pi­tals. Mem­bers must cover the short­fall if doc­tors and spe­cial­ists charge more than the schemes’ rates.

Some mem­bers have made up for this by buy­ing gap cover prod­ucts to cover the short­fall.

The Coun­cil for Med­i­cal Schemes has pre­vi­ously said this has posed a “se­ri­ous” threat to med­i­cal scheme risk pools and gov­ern­ment’s pro­posed Na­tional Health In­sur­ance pro­gramme.

But Larkan be­lieves gap cover is “ab­so­lutely nec­es­sary” as mem­bers might be faced with the im­pos­si­ble choice of need­ing to see a spe­cial­ist other than those named on the scheme’s net­work.

Schemes are feel­ing un­der­mined be­cause some mem­bers have opted to join plans that of­fer a 100% scheme tar­iff for in-hos­pi­tal costs, which are cheaper than their 200% or even 500% equiv­a­lents, and have bought gap cover for any fu­ture short­falls.

The sur­vey did not an­a­lyse Pre­scribed Min­i­mum Benefits (PMB) or chronic-ill­ness cover, which GTC as­sumed was paid from the risk pool, while ac­knowl­edg­ing that the level of cov­er­age dif­fers across plan types.

The Coun­cil for Med­i­cal Schemes said PMB ben­e­fit pay­outs ac­counted for 53% of pay­outs from scheme risk pools in the 2013 fi­nan­cial year.

Hy­per­ten­sion, hy­per­lip­i­daemia, di­a­betes mel­li­tus type 2 and asthma were the most preva­lent chronic con­di­tions cov­ered by PMBs.

City Press has eval­u­ated cover for med­i­ca­tion and equip­ment needed to treat th­ese con­di­tions across the pre­ferred and sec­ond-best plans iden­ti­fied by GTC (

This showed that more ex­pen­sive plans did not nec­es­sar­ily pro­vide greater cover for chronic med­i­ca­tion. Some, like Fed­health’s Max­ima Ba­sis plan, use re­stricted for­mu­la­ries.

Some med­i­cal schemes do not pub­lish their for­mu­la­ries – or lists of chronic med­i­ca­tion and equip­ment they cover – and did not re­spond to re­quests for th­ese.

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