Coping with soaring cost of medical aid
Study benefits of cheaper plans
Medical scheme contributions will increase by approximately 7.75% on average this year and many schemes are passing an increasing amount of risk of paying for healthcare services on to you.
This is according to Jill Larkan, the head of healthcare at GTC, who calculated the average increases on nine large medical schemes.
If your salary has gone up by less than the increase in your medical scheme contributions, you may find the increased contributions an additional financial burden and may be looking to move to a cheaper option, known as buying down.
If you are thinking of buying down, make sure you check these benefits before you do: 100% cover does not mean you are covered in full.
Cheaper schemes pay specialists who treat you in hospital at lower rates, which means you need to seek out those rare doctors who do charge lower rates, or, if your scheme has doctors in a network that charge the scheme rate, use one of them.
If a scheme says it offers cover for procedures in hospital at 100%, this only means it pays the tariffs your scheme has drawn up. It does not mean your scheme will pay 100% of the costs a specialist charges to treat you in hospital, Larkin says. If your specialist charges more than your scheme pays – between one-and-a-half to five times the tariff is common you will have to pay the balance yourself. You can also take out short-term insurance, known as gap cover, to cover the difference in the rates.
Low medical savings
Many medical schemes offer cover for less serious out-ofhospital visits to a doctor and for optometry, medicine and dentistry through medical savings accounts.
Larkin says these accounts allow medical schemes to limit the amount they have to pay out. Once your medical savings account is depleted, you have to pay for the costs out of your own pocket, she says.
Always check how much you will contribute to your medical savings account for the year and how this compares to what you typically spend on out-of-hospital costs for the year.
If you know the contributions are too little, but can’t afford a more expensive medical scheme option, set aside an amount each month in a separate savings account that you only use for medical expenses not covered by your scheme.
Chronic medicines
Many medical schemes, and especially the cheaper ones, specify the pharmacy you must use to get medicines for a chronic (ongoing) condition such as high blood pressure or cholesterol, Larkin says.
This limits the costs for your scheme. If you use a different pharmacy, you will have to pay the difference in cost out of your own pocket.
Cheaper medical schemes typically have lists of approved medicines or formularies with cheaper generic medicines. They will only pay for the cost of those medicines and not more expensive ones.
They are also unlikely to cover chronic medication for conditions that they do not, by law, have to cover.
Cancer benefits
Cancer benefits are typically trimmed down as you move to cheaper options. Check that expensive scans you may need are covered and that there is a substantial benefit to cover expensive oncology medicines. If you need to accept a lower annual benefit limit for cancer to reduce contributions, check if you have severe illness cover.
Cover for big ticket items
Larkin says if you are anticipating any big medical events for the year ahead, such as childbirth, or decisions to have significant elective operations or even special dental treatment, you need to check how the scheme will cover the procedure, and possibly an extended hospital stay, the cost of specialists and aftercare.
Cheaper schemes tend to limit cover for expensive procedures such as organ transplants or to only offer cover in state hospitals. Also check the cover for artificial eyes and limbs as well as appliances such as wheelchairs, because these can be very expensive.
Ambulance and emergency services
Make sure you are covered for emergency ambulance services, including emergency evacuation. Be aware of which emergency ambulance service your medical scheme covers.
100% cover does not mean you are covered in full