WHAT YOU NEED TO CONSIDER WHEN CHANGING OPTIONS
THE BOARD of Healthcare Funders of Southern Africa, which represents medical schemes and administrators, recommends that you consider the following if you’re moving options:
• Your health. It is important to look at the benefits offered by the new option in the light of your health needs. If you are relatively young and healthy and won’t need much medical attention in the course of the year, it might pay to move to a low-cost option. However, if you are getting older, have a family history of a medical condition, or suffer from a chronic condition that may not be covered, it may not be wise to change to a low-cost option.
• PMB cover. All options must, by law, cover the prescribed minimum benefit (PMB) conditions, a list of lifethreatening and chronic conditions laid down in the regulations. However, you and your doctor have to convince the scheme that your condition falls within the PMBs before it will pay for it. Some schemes may ask you to use a specified provider if you want to be covered in full, and many have a series of “application” forms that have to be completed before you are covered.
• Medications and treatments covered. If you change from a highend to a low-benefit option, you could find that medicines and treatments that were paid for aren’t covered on the lower option. An example is antidepressants and anxiety medications – only the higher-cost options tend to pay for these. Also, drugs listed for specific conditions may be different from the ones you are using. The medication you are on for your high blood pressure or high cholesterol may have to be changed to a brand (or generic) that appears on the option’s formulary if the scheme is to pay for it in full.
• Are your regular providers catered for? When changing options, you may find that you can’t use your family GP unless you pay the fees yourself. Or you may have to travel to a hospital on the other side of town to have an operation or see a specialist, because those closest to you aren’t on the list. If your current GP or specialist is not a member of the scheme’s provider network, you may have to change doctors.