Maya Fisher-French un­packs the op­tions

CityPress - - Tenders -

Dis­cov­ery and Mo­men­tum med­i­cal schemes topped the ta­bles in this year’s GTC Med­i­cal Aid Sur­vey across most plans. The ex­ten­sive sur­vey, con­ducted by fi­nan­cial ad­vi­sory busi­ness GTC, takes var­i­ous cri­te­ria into ac­count when rank­ing the scheme op­tions. Jill Larkan, head of health­care con­sult­ing at GTC, says that, when se­lect­ing a med­i­cal scheme for clients, they al­ways con­sider the sus­tain­abil­ity of the fund in the long term.

“On the mi­cro level, we com­pare the pre­mi­ums in the rel­e­vant cat­e­gories and then we look at 10 ma­jor macro cri­te­ria,” says Larkan, who ex­plains that the macro cri­te­ria pro­vide a good idea about the sus­tain­abil­ity of the fund, and whether or not the fund will be able to con­tain pre­mium in­creases in the fu­ture.

The GTC sur­vey looks at the num­ber of mem­bers on the scheme; growth in mem­ber­ship year on year, and over a three-year pe­riod (in­di­cat­ing trends de­vel­op­ing); year-on-year growth within the pool of mem­bers over a one- and three-year pool (in­di­cat­ing whether one scheme was able to at­tract mem­bers from an­other); sol­vency ra­tio; net health­care re­sults over a one- and three-year pe­riod; the av­er­age age of the mem­bers; and the num­ber of com­plaints re­ceived on the Hello Peter web­site.

A fund is more likely to be sus­tain­able if it has a sol­vency ra­tio of at least 25%, a rel­a­tively low av­er­age ben­e­fi­ciary age (37 or younger) and a broad mem­ber­ship base.

Just look­ing at the cheap­est fund does not take into con­sid­er­a­tion the sus­tain­abil­ity of the fund. If a fund is ex­pe­ri­enc­ing higher claims than pre­mi­ums, it will even­tu­ally in­cur higher pre­mium in­creases or col­lapse.

The sur­vey com­pared op­tions across dif­fer­ent lev­els:


The top three rated schemes for en­try-level plans (within the state only, and for low and mid salary­banded cat­e­gories) in­clude:

. Makoti Pri­mary (state only for hospi­tal);

. Mo­men­tum Ingwe (state only for hospi­tal); and

. Dis­cov­ery KeyCare Ac­cess (state only for hospi­tal – ex­clud­ing ma­ter­nity).

These plans pro­vide in-hospi­tal and out-of-hospi­tal ben­e­fits, but within a lim­ited list of doc­tor and hospi­tal net­works, and for lim­ited med­i­ca­tions. These are aimed at young first-time work­ers, and many al­low mem­bers ac­cess to pri­vate hos­pi­tals as well as GPs, den­tists and op­ti­cians, for ex­am­ple. Most plans charge based on the salary earned, so al­though the ben­e­fits re­main the same for all mem­bers, the higher-in­come earn­ers are cross-sub­si­dis­ing lower earn­ers.


The top three rated schemes in­clude:

. Dis­cov­ery plans: Es­sen­tial Smart, Es­sen­tial Delta Core and Costal Care;

. Ge­n­e­sis Pri­vate Choice; and

. Mo­men­tum Cus­tom.

These pro­vide for in-hospi­tal cover only, but in­clude out-of-hospi­tal cover of chronic ill­ness and pre­scribed min­i­mum ben­e­fits as set out by the Med­i­cal Schemes Act.


The top three rated schemes in­clude:

. Dis­cov­ery Es­sen­tial Delta Saver, Clas­sic Delta Saver, Coastal Saver;

. Mo­men­tum In­cen­tive; and

. Topmed Ac­tive Saver.

A saver plan pro­vides in-hospi­tal ben­e­fits at var­i­ous lev­els and also pro­vides ac­cess to out-of-hospi­tal ben­e­fits via an out-of-hospi­tal ben­e­fit or sav­ings ac­count.


The top three rated schemes in­clude:

. Mo­men­tum Ex­ten­der;

. Dis­cov­ery Es­sen­tial Delta Com­pre­hen­sive, Clas­sic Delta Com­pre­hen­sive, Es­sen­tial Com­pre­hen­sive, Clas­sic Com­pre­hen­sive, Clas­sic Com­pre­hen­sive R0 MSA; and

. Topmed Ex­ec­u­tive.

These plans have un­lim­ited above-thresh­old ben­e­fits or un­lim­ited sec­ondary out-of-hospi­tal ben­e­fits.


When se­lect­ing the cor­rect scheme or op­tion for your needs, you need to con­sider the ben­e­fits of­fered and whether they suit your needs.

What is the level of hospi­tal cover?

More than three-quar­ters (76%) of plans of­fer only 100% med­i­cal scheme rate cover for in-hospi­tal costs. Only 28 plans of­fer 200%, and only seven of­fer 300%.

“It is im­por­tant to in­clude a gap cover in­sur­ance as part of your med­i­cal cover be­cause most pri­vate hos­pi­tals charge above the med­i­cal scheme rate,” says Larkan.

What are the an­nual lim­its?

Five med­i­cal schemes still im­pose over­all an­nual lim­its on risk cover, which aims to man­age the scheme’s risk ex­po­sure. If there are lim­its on your plan, you need to un­der­stand what those are and how they af­fect you. The schemes in­clude Commed, Topmed, Mo­men­tum, Com­p­care and Hosmed.

Un­til what age is my child cov­ered?

Most schemes cover chil­dren up to the age of 21, how­ever, some schemes al­low a child to re­main a de­pen­dant un­til the age of 28. More than half of the schemes only charge for ei­ther the first two, three or four chil­dren. For ex­am­ple, if your plan only charges for the first three chil­dren and you have four chil­dren, your fourth child is cov­ered for free.

What chronic ben­e­fits do you of­fer?

More than 60% of med­i­cal plans of­fer additional chronic ill­ness ben­e­fits over and above the pre­scribed min­i­mum ben­e­fits. These tend to be higher-end plans, with some com­pre­hen­sive plans such Makoti Com­pre­hen­sive and Profmed’s ProPin­na­cle of­fer­ing un­lim­ited chronic ill­ness cover.

What ma­ter­nity ben­e­fits do you pro­vide?

Most schemes pro­vide for ma­ter­nity ben­e­fits from the risk por­tion and not from sav­ings ac­counts. Larkan says this en­cour­ages younger mem­bers to re­tain their cover and to en­sure they are on the right plan as ma­ter­nity ben­e­fits have no af­fect on their sav­ings ac­count. Check what additional ben­e­fits are pro­vided as these vary by plan. For ex­am­ple, nearly 60% of plans of­fer spe­cial­ist con­sul­ta­tions, only 20% of­fer an­te­na­tal classes and 60% of­fer scans.

What is your can­cer cover?

Nearly three-quar­ters of plans of­fer on­col­ogy treat­ment lev­els above the pre­scribed min­i­mum level, with seven plans of­fer­ing un­lim­ited cover – these in­clude Fed­health Max­ima Plus and Ul­ti­max, Mo­men­tum Sum­mit and Medi­help Plus. If your scheme does not have ex­ten­sive can­cer cover, you can top up through gap cover in­sur­ance.

What else do you cover from risk and not sav­ing?

The more bills paid from risk and not sav­ings means that your day-to-day sav­ings last longer. About 30% of schemes pay for con­tra­cep­tion from risk, and nearly 50% of schemes cover spe­cialised ra­di­ol­ogy such as MRI and CT scans from risk. Many schemes also cover emer­gency hospi­tal vis­its or trauma events from risk.

Most schemes now cover pre­ven­tive doc­tor vis­its or med­i­ca­tion from risk cover, in­clud­ing flu vac­ci­na­tions, pap smears, choles­terol tests and mam­mo­grams. This en­cour­ages mem­bers to take their an­nual tests as it does not af­fect their day-to-day med­i­cal sav­ings.


Six med­i­cal schemes specif­i­cally of­fer stu­dent plans aimed at full-time stu­dents. For less than R350 a month, a stu­dent can get hospi­tal cover, as well as vis­its to GPs and den­tists, for ex­am­ple.

The top three rated schemes are Makoti Pri­mary, Topmed Net­work and Mo­men­tum Ingwe. Makoti charges R225 a month, but only pro­vides state hospi­tal cover. Mo­men­tum (R335 a month) and Topmed (R319 a month) in­clude pri­vate hos­pi­tal­i­sa­tion.

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