HOW COSTS ARE CONTAINED

Medical schemes do not have unlimited resources, and the cost of medicines, medical technology and the tariffs demanded by doctors and specialists are increasing every year at rates that exceed the headline inflation rate.

Schemes have implemented measures to contain costs and ensure that members do not abuse their benefits. These measures benefit members, because they keep contribution increases under control. The measures include: • You have to obtain preauthorisation for hospitalisation and for certain procedures.

• You may have to register on a chronic medicine programme to receive cover for chronic conditions.

• Schemes provide benefits that cover doctors at set rates. If your doctor charges more than this rate, you will face an out-of-pocket payment. However, if the condition is a prescribed minimum benefit, the scheme must pay in full.

• Schemes draw up treatment protocols and medicine formularies. Your doctor may recommend a treatment that is not in line with the scheme’s protocol or a medicine that is not on its formulary. In some cases, the scheme will not cover an alternative treatment or medicine, but in some cases you may receive payment up to the amount the scheme would have paid had you followed its treatment protocol or used its formulary medicine.

• Schemes set limits on benefits or impose co-payments, which means you may still face some medical bills that you will have to pay yourself.

• Schemes will not cover all healthcare costs – they will not, for example, pay for cosmetic procedures or untested treatments.