Choos­ing a med­i­cal scheme op­tion that’s right for you

Novem­ber or De­cem­ber is typ­i­cally when you de­cide whether to stay on your med­i­cal scheme op­tion or move to another one. Laura du Preez re­ports on what you should con­sider when mak­ing up your mind.

Weekend Argus (Saturday Edition) - - PERSONALFINANCE -

At this time of the year, you are likely to re­ceive a let­ter from your med­i­cal scheme in­form­ing you of con­tri­bu­tion in­creases and changes to its ben­e­fit op­tions for next year.

So what should you con­sider when you re­view your med­i­cal scheme cover?

Daniel Le­hutjo, the act­ing chief ex­ec­u­tive of­fi­cer and reg­is­trar of the Coun­cil for Med­i­cal Schemes, ad­vises peo­ple to re­view their health­care claims and cur­rent state of health. Make a list of your claims over the past three years and take into ac­count any fu­ture needs of which you are aware.

“Price is not the only de­ter­min­ing fac­tor. We ad­vise peo­ple to look at their cur­rent and fu­ture health­care needs,” Le­hutjo says.

Gen­er­ally, the more free­dom it gives you to choose a health­care provider, treat­ment or med­i­ca­tion, the more an op­tion will cost.

There is a dif­fer­ence be­tween acute con­di­tions, such as bron­chi­tis, which you con­tract and re­cover from and chronic con­di­tions, such as high blood pres­sure or high choles­terol, which re­quire on­go­ing treat­ment. Some com­mon chronic con­di­tions are pre­scribed min­i­mum ben­e­fits (PMBs), which means the scheme must pay in full for the med­i­ca­tion, as well as for tests and con­sul­ta­tions re­lated to the con­di­tion.

First, en­sure that your hos­pi­tal cover and chronic cover suits your needs, and then weigh up the cost of buy­ing day-to-day cover for vis­its to a gen­eral prac­ti­tioner (GP) for acute con­di­tions, medicines for acute con­di­tions, den­tistry and op­tom­e­try against sav­ing enough to self-fund these ex­penses.

If you don’t have the dis­ci­pline to save, choose an op­tion with ei­ther good day-to-day cover or a med­i­cal sav­ings ac­count, which will force you to save for these costs.

Here are some of the things you should con­sider when weigh­ing up one op­tion against another:

Most op­tions limit the med­i­cal care they will fund. In this re­gard, there is a dif­fer­ence be­tween tra­di­tional ben­e­fit op­tions and new-gen­er­a­tion op­tions, Elsabe Con­radie, the head of stake­holder re­la­tions at the Coun­cil for Med­i­cal Schemes, says.

Tra­di­tional ben­e­fit op­tions do not have a med­i­cal sav­ings ac­count and fund all claims from the over­all an­nual ben­e­fit, whereas mod­ern ben­e­fit op­tions have a med­i­cal sav­ings ac­count that is used to fund cer­tain ser­vices, such as GP vis­its and acute medicines, she says.

The over­all an­nual ben­e­fit may have var­i­ous sub- di­vi­sions with their own ben­e­fit lim­its. For ex­am­ple, an op­tion has an an­nual limit of R500 000 per fam­ily. This limit in­cludes ben­e­fits or ser­vices for “ma­jor” events, such as MRI and CT scans, which have a sub-limit of R5 000 per fam­ily, Con­radie says. If a mem­ber has scans that cost more than R5 000 (for ei­ther the fam­ily or one de­pen­dant), the med­i­cal scheme will pay up to R5 000 only.

Most med­i­cal schemes have sub­lim­its on pros­the­ses, such as ar­ti­fi­cial joints and other de­vices, and you may have to meet cer­tain cri­te­ria to qual­ify for the ben­e­fit.

Cancer (on­col­ogy) ben­e­fits are also usu­ally stip­u­lated as a spe­cific amount – for ex­am­ple, R250 000 per fam­ily a year, Con­radie says.

It is im­por­tant to take note of the over­all limit, the sub-lim­its for cer­tain ser­vices and the rules that ap­ply to the sub-lim­its. But re­mem­ber that the lim­its and sub-lim­its may not ap­ply to the pay­ment of ac­counts for PMBs, Con­radie says.

PMB ac­counts may be paid from the an­nual ben­e­fit if this is in the scheme’s. But if the PMB ac­counts de­plete the an­nual ben­e­fit, your scheme must con­tinue to pay for PMB treat­ment.

Reg­u­la­tion eight un­der the Med­i­cal Schemes Act spec­i­fies that your scheme may ap­point one or more des­ig­nated ser­vice providers (DSPs) for the di­ag­no­sis, treat­ment and care of PMB con­di­tions.

If you choose not to use the DSP, the scheme may charge a co-pay­ment, Con­radie says. The co-pay­ment must be spec­i­fied in the scheme’s rules. It can be a per­cent­age of the cost, the dif­fer­ence be­tween the scheme’s rate and the ac­tual cost, or a fixed amount.

Not us­ing a DSP may ex­plain why your claims on your cur­rent op­tion are not be­ing paid, or are not be­ing paid in full. You also need to know whether any DSPs have been ap­pointed for an op­tion you may be con­sid­er­ing join­ing.

If you have a PMB con­di­tion and the DSP is not within a rea­son­able dis­tance of where you live, or is not avail­able within a rea­son­able pe­riod of time, or you re­quire im­me­di­ate treat­ment, your scheme may not im­pose a co-pay­ment.

A scheme may have a list of medicines, known as a for­mu­lary, for which it will pay in full. If you vol­un­tar­ily use a medicine that is not on the list, the medicine may not be cov­ered, or the scheme may im­pose a co-pay­ment, even if it is a chronic con­di­tion that is a PMB.

The co-pay­ment must be spec­i­fied in the scheme’s rules. Again, it can be a per­cent­age of the cost, the dif­fer­ence be­tween the scheme’s rate and the ac­tual cost, or a fixed amount, Con­radie says.

If you have a PMB chronic con­di­tion and none of the medicines on the for­mu­lary is ef­fec­tive, or they have harm­ful side-ef­fects, the reg­u­la­tions un­der the Med­i­cal Schemes Act oblige your scheme to fund the pre­scribed medicine with­out im­pos­ing a co-pay­ment, Con­radie says.

An op­tion may have a limit on what it pays doc­tors who treat you in hos­pi­tal. For ex­am­ple, your scheme may re­im­burse doc­tors at 200 per­cent of the scheme’s rate. How­ever, there are no lim­its on what doc­tors may charge, so your doc­tor may charge 400 per­cent of the scheme’s rate.

Un­less your scheme has ap­pointed a DSP, it may be obliged to pay what­ever rate the doc­tor charges if your con­di­tion is a PMB.

Schemes may con­tract with health­care providers in a pre­ferred provider net­work to charge at a par­tic­u­lar rate for non-PMB con­di­tions, Con­radie says. By us­ing one of these providers, you can avoid cases where your med­i­cal scheme will im­pose a co-pay­ment.

If your scheme has a pre­ferred provider for a non-PMB con­di­tion and you do not use that provider, your scheme may limit what it will pay to­wards the ac­count, she says.

Some cheaper op­tions of­fer ben­e­fits through a net­work of health­care providers only. The rules of these op­tions usu­ally pro­vide for a lim­ited num­ber of con­sul­ta­tions or other ben­e­fits ob­tained out­side of the net­work. But in these op­tions the net­work will also be the DSP, and the reg­u­la­tions about us­ing non-DSPs, as out­lined above, will ap­ply.

Schemes are en­ti­tled to use man­aged-care pro­to­cols to en­sure that your treat­ment is cost-ef­fec­tive and af­ford­able, but they must be “ev­i­dence­based”, which means they must have been con­firmed by sci­en­tific stud­ies, Con­radie says.

Your doc­tor may pre­scribe treat­ment for a PMB con­di­tion, such as cancer, that is not ev­i­dence-based, or is sup­ported by sci­en­tific stud­ies but is not cost-ef­fec­tive for the scheme. In that case, the treat­ment will not be cov­ered by the PMBs.

The PMBs are the min­i­mum treat­ment that med­i­cal schemes must fund, and the reg­u­la­tions state that this min­i­mum is the treat­ment avail­able in the state health­care sec­tor, Con­radie says. If the treat­ment pre­scribed by your doc­tor is not avail­able in the state sec­tor, the scheme can­not be com­pelled to fund this treat­ment in full. In such a case, your scheme may fund the treat­ment to the limit of the treat­ment in the state sec­tor. Schemes use these to pre­vent mem­bers and their doc­tors from us­ing ex­pen­sive ser­vices when they are not ab­so­lutely nec­es­sary.

The Med­i­cal Schemes Act states that only 25 per­cent of the mem­ber’s to­tal con­tri­bu­tion may fund a med­i­cal sav­ings ac­count that is used to pay for day-to-day med­i­cal needs that are not PMBs.

Work out the amount you con­trib­ute and com­pare it with your day-to-day, non-PMB med­i­cal needs. If it is not enough, you need to con­sider set­ting aside your own sav­ings for these needs, or mov­ing to a higher op­tion. When you con­sider what to do, eval­u­ate the ad­di­tional cost of a more ex­pen­sive op­tion against the ad­di­tional ben­e­fits and whether you need them.

Check whether an op­tion has above- thresh­old ben­e­fits, which cover your day-to-day costs once you have de­pleted your med­i­cal sav­ings ac­count, Con­radie says. Typ­i­cally, these ben­e­fits are of­fered on more ex­pen­sive op­tions.

The ex­pen­di­ture you must in­cur be­fore the in­sured ben­e­fits ap­ply is typ­i­cally higher than your sav­ings ac­count bal­ance, so you will have to pay your own claims while you are in this “self-pay­ment gap”.

PMBs may never be funded from a med­i­cal sav­ings ac­count. Even if you have de­pleted your med­i­cal sav­ings ac­count and your an­nual ben­e­fits, the scheme must still pay your PMB ac­counts, although pro­to­cols, for­mu­la­ries and DSPs may ap­ply, Con­radie says.

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