Medical aid – the devil is in the detail
COVID-19 has highlighted the need for quality healthcare. Although medical aid is sometimes perceived as a “grudge” purchase, it is when we face unexpected and expensive medical costs that we realise how important it is to have private medical care.
Broker’s role is critical
The most common frustration voiced by medical scheme members is that they don’t understand their benefits. There is a misperception that medical aid contributions cover all healthcare expenses and that medical schemes are obliged to pay for these in full. However, this is not always the case and several factors must be taken into account.
It is for this reason that medical aid schemes, along with brokers and financial advisors, have a responsibility to help members become empowered and aware of medical aid regulations, scheme rules and terminologies such as PMBs, DSPs, day-to-day benefits, co-payments, limits, sub-limits and savings.
Day-to-day detail
Medical aids are not-for-profit and belong to their members, which is why they have a responsibility to manage the funding pool for the benefit of all their members. It is important to look carefully at the day-to-day benefits and ask:
• Does your medical aid contract with hospitals, doctors and specialists? Are you willing to use them and are they close by? Network providers are there to ensure full or improved cover and charge a pre-negotiated rate. This means doctors and hospitals on your scheme’s network will not charge more than the agreed rate. Not using network providers will usually result in a co-payment.
• Check if you need to be referred to a specialist by your GP.
• Does your medical aid offer additional GP consultations, for which they will pay, after you have exhausted your day-to-day benefits?
Age impacts your decision
• If you have young children, select an option with enough childcare benefits.
• Check the maximum age of child dependents.
• If you’re older, select a cover that provides sufficient in-hospital cover in the event of hospitalisation, and that also has sufficient cover for chronic conditions as our health deteriorates as we age.
Additional benefits
Ask what extra benefits might be available that could save significantly on day-to-day expenses. These could include preventative care benefits (such as flu vaccines, pap smears and prostate screenings) to wellness benefits (including blood pressure, cholesterol, blood sugar and BMI measurements). In some cases, this extends to healthcare advice lines, maternity programmes, dental check-ups and more.
Ensure plan affordability
When comparing different medical aid options, consider all the costs involved before you make your final decision. Such as:
• Monthly contributions: as a rule of thumb, these should be around 10% of your monthly income if you are healthy, with a greater allocation if you have healthcare concerns and pre-existing conditions.
• Generally, the lower the cost of the option, the fewer the benefits. Ensure that your healthcare needs will be met by the plan you select.
Read and compare
A common error is to choose a medical plan based on costs, but the advice is to rather base your selection on the value and valueadded benefits. For example, if a medical aid covers MRIs, this does not mean that it is unlimited. Radiology is expensive, so even the top plans limit the number of CT scans, MRIs and other radiology available.
Medical aid needs are dynamic, so plans should be reviewed annually. The Bonitas website allows for easy comparison to help members make informed choices.
Empower yourself with information
Take the time to read the information sent to you by the medical scheme, or consider using a broker. Brokers know the details of the different plans and can help match you with the best medical cover. Covid-19 retrenchments and reduced salaries mean professional advice is even more important.
Your health and that of your family is important. It is vital that you are comfortable with the choice you make and confident that your healthcare needs will be taken care of. The devil is often in the detail, so having an understanding and knowledge of important information is imperative. Make sure that you are informed. Read the information and fine print, and compare what the different plans are offering before you commit. If you are still unsure, you can phone the scheme or check with your broker or financial advisor.