What to know about medical aid

TIPS: MAKE AN INFORMED CHOICE ABOUT PLANS

Medical aids are regulated by the Medical Schemes Act of 1998 and the Council for Medical Schemes is responsible to ensure compliance.

Each medical scheme must have a Board of Trustees who manage and control the scheme affairs, with a set of rules which members are entitled to see. Members can also attend the scheme’s AGM and vote for trustees.

Medical schemes have several plan options, differing according to benefits and contributions. Contributions may vary according to family size, make-up and income. Find out if your option requires you to use certain providers: using a provider outside the network could mean paying in for the bill. You can change your selected option yearly.

Some options require you to only use specific hospitals for planned treatment; this cover may pay at certain rates or have an overall limit. Members are usually required to notify the scheme before planned hospitalisation and are given an ‘authorisation number’ confirming the procedure will be covered at the option rate. Many providers (e.g. specialists) may charge above the scheme rate of payment. This bill is then your responsibility.

Out of hospital cover – Day to day benefits (e.g. GP visits or medication) are covered by some options, via a savings account, or sometimes by a set scheme benefit. Know your benefits and amounts and the rate charged.

The Act sets out certain Prescribed Minimum Benefits (PMBs), which all schemes must pay for, regardless of your option. These PMBs cover various serious conditions; review them if you suffer from any condition or expect to have treatment. The scheme is entitled to apply their own rules.

Chronic conditions are usually described as potentially life threatening conditions where ongoing medication is required. The PMBs set out 25 chronic conditions the scheme must cover, within set guidelines. Register for these conditions so it doesn’t affect your other day to day benefits. The scheme may only pay certain medication amounts or for specific medications.

Providers can charge different rates, but your scheme option will pay only at a specified rate. The ‘100% of scheme tariff/rate’ doesn’t mean your healthcare provider will be paid in full – they may charge substantially more than this scheme rate. Negotiate with your doctor to ensure you get the best possible rate.

Many providers are prepared to negotiate their charges upfront if members are honest – before treatment. If they realise you’re concerned about finances, they may try to find more cost-effective, but still appropriate treatment, or consider dropping their fees.

Ensure your health cover is appropriate for your changing needs in various life stages. Consider using an independent specialist healthcare advisor or relevant broker.

Victor Crouser is coastal head of healthcare for Alexander Forbes Health