Mind self-payment gaps

USEFUL TIPS: MEDICAL INDUSTRY EXPERTS SHARE THEIR VIEWS

Look for schemes offering benefits paid from risk, which offer more value for money.

Medical aid self-payment gaps are reduced only by claims members pay at medical aid rates, among other things, Chartered Employee Benefits healthcare specialist Devlin Ross says.

If you pay a GP a R500 consultation fee, but the medical aid rate is R320, your self-payment gap will only reduce by R320.

As such:

Evaluate your medical plan: what you’re covered for, at what rates, with which providers and if a specific hospital or pharmacy network must be used, says Deon Kotze, Discovery Health research and development head.

A comprehensive top plan will avoid any self-payment gaps but can be costly, adds Pascale Bargehr, Total Risk business development officer.

Ross says if you’ve been on a plan for two years or more and have never closed your self-payment gap, you’re probably over-insured. A financial adviser can help.

Look for schemes offering benefits paid from risk. These benefits offer more value for money.

When entering a self-payment gap, ask your scheme what counts towards closing the gap and then maximise benefits, writes ThinkMoney.

Always use a partner network hospital, doctor or pharmacy: you’ll be charged at the agreed rate. This avoids co-payments, deductibles and out-of-pocket expenses, says Gerhard van Emmenis, Bonitas Medical Fund acting principal officer.

While using your medical savings and when in your self-payment gap use service providers who charge medical aid rates, says David Narun of Informed Healthcare Solutions.

“If [hospital] procedures attract a co-payment, negotiate with the provider on alternative/more conservative treatment protocols where possible,” says Ann Streak, Alexander Forbes Health senior consultant.

Van Emmenis and Kotze share a few more tips:

Use managed-care benefits

Some schemes offer preventative care benefits, paid from risk, not from savings, including oncology, HIV and diabetes management programmes.

Pharmacists can provide sound advice on some medical problems such as rashes or colds.

Pay cash for over-the-counter medicine for less serious ailments and consider cheaper, effective generics.

Know doctors’/specialists’ rates. Ask what rates your doctor charges and if you’ll be liable for co-payments.

Register chronic diseases. You may qualify for chronic medication benefits, which your scheme pays for from risk. Ask your doctor/pharmacist if your prescribed medicine is covered in full. If not, ask about alternatives.

Pre-authorise all hospital admissions to ensure you’re covered. Ask if co-payments or sub-limits apply and how to avoid them. Ask your scheme if you’ll have better cover for planned procedures by using contracted providers or having the procedure in a doctor’s rooms or day clinic.

Read information (fine print, scheme rules) sent by your scheme or financial advisor. Use your scheme’s preventative screening benefits for health checks.