WHAT YOU NEED TO CON­SIDER WHEN CHANG­ING OP­TIONS

Saturday Star - - INSIGHT -

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.

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