How to navigate the minefield of choosing the right medical plan
It’s that time when medical schemes allow you to change the plan you are on. Here’s what you need to know.
If you are staying on the same medical scheme but simply downgrading or upgrading from one plan to another, your cover will change from 1 January 2021 with no waiting period. However, if you choose to switch from one scheme to another, you must apply for membership to the new scheme. The new scheme will evaluate your previous membership and decide if a waiting period — in general or on specific conditions — will apply.
Annele Oosthuizen, branch manager at Alexander Forbes Health, says if you can prove that you have already been on a medical scheme for at least two years, you will automatically qualify for all prescribed minimum benefits (PMBs) with immediate effect. “Most chronic conditions fall under the PMBs so you are likely to be able to access your chronic meds if you can prove this. PMBs also include emergencies, so for example, if you require emergency hospital care after a car accident, that would be covered,” she says.
The choice you make now will determine the level of healthcare benefits you qualify for and how much you will pay over the next year. These are the questions to ask:
What are your healthcare needs? Damian McHugh, head of sales and marketing at Momentum Health, says when he was an adviser, he would ask clients if they were healthy and the reply would be “yes”. “As you start asking more questions, you find out that there are family members who wear spectacles, the son uses braces, the daughter has asthma and the wife is diabetic. This is a family with real medical needs and high medical costs,” he says.
What do you spend on healthcare each year?
McHugh says he looks at his family’s healthcare expenditure each year and then adjusts his medical scheme savings account contributions for the year ahead. “You often find members who have chosen a hospital plan because they think it is more affordable but then they are spending R15,000 a year on out-of-hospital healthcare. On the flip side, you have members who opt for the most expensive plan and then don’t use half the options available to them. In that case, instead of spending R7,000 a month, you could downgrade to a lower benefit plan, pay R3,500 a month and invest the other R3,500,” he says.
He adds that you can ask your medical scheme for an annual claims statement, which will tell you what your healthcare costs have been for the year. “If you have been submitting all your healthcare claims to your medical scheme regardless … the claims statement will include all the declined claims and will show what you paid out of your own pocket,” he says.
What does the plan cover?
Janette Clark, senior account manager at Aon South Africa, says you should compare the benefits, exclusions, value adds and service delivery with your specific healthcare needs such as chronic conditions and regular medication. “[For] example, a family that needs access to cover for chronic conditions may find that downgrading will increase their out-of-pocket expenses by more than the contribution savings,” she says.
Will you be liable for co-payments? 100% cover does not always mean you are fully covered. Specialists and in-hospital charges can be up to 400% of the benefits offered by a medical scheme. So, if your medical scheme only pays out 100% of tariff, you will be liable for the shortfall.
Do you have to use a designated service provider network?
Some medical scheme options require that you make use of specified practitioner and hospital networks. Step out of this network and you could face significant co-payments.
Choosing the right plan can be complicated. For advice you can find a list of approved medical scheme brokers on the website of the Council for Medical Schemes. DM168