Things to look for in medical aid schemes

Financial pressures and sweeping changes across the medical aid industry may push many people into reassessing their medical scheme cover and into switching in 2014.

Graham Anderson, Principal Officer at Profmed, the medical scheme catering exclusively to graduate professionals, says it is critical for people to regularly re-asses the medical scheme option that they are on to ensure that it is still appropriate to their family’s health profile and their financial circumstances.

“People’s needs change all the time. Furthermore, medical schemes usually review their benefits on a yearly basis. Therefore, a review of one’s option should ideally take place on an annual basis or whenever a member goes through a life-changing event,” he says.

For example, Anderson says, a person who has recently acquired a degree could qualify to belong to a medical scheme that offers more specialised services and additional benefits for degreed professionals.

“Life stage also plays an important role when considering a medical scheme. A single young professional or a young couple are unlikely to require comprehensive cover but rather a good hospital option, preferably with no limits on hospitalisation and no co-payments or deposits on admission to hospital.

Alternatively, a family with children would probably require a more comprehensive option, which includes out-of-hospital benefits. Once again, it is important to ensure that the hospital benefits and benefits for the major dread diseases are comprehensively covered,” says Anderson.

Anderson explains that switching to a cheaper option or a hospital option could have some significant financial benefits – but only if the member is able to carry the cost of out-of-hospital medical expenses e.g. doctors consultations, acute medicine etc..

The cost of different options depends on both the level of benefits offered as well as the health of the average member on the option. Generally, less healthy members tend to belong to options offering more benefits – which often make these options more expensive.

“By switching to an option with fewer benefits members should be grouped with healthier members, and therefore pay lower contributions. The savings made through lower contributions could be used for GP visits and other expenses out of pocket as they are needed,” he says.

Anderson also urges members to make sure they know their rights with regards to the Prescribed Minimum Benefits (PMB’s), as this will also aid in the understanding of the best option to choose.

“Essentially, there are certain conditions that a medical scheme is obliged to cover, irrespective of the option you are on. This means that even if a member is on a hospital option, he or she must be covered for PMB’s, including those incurred out of hospital,” he says.

Another important consideration is that some medical schemes make use of Designated Service Providers (DSP’s) which members will be obliged to use for treatment to avoid having to make a co-payment. In the above example, a member with hypertension may be required to use a specific pharmacy and GP.

Anderson says members must make sure that they are happy with the DSP’s available before they commit to an option for 2013.

He cautions, however, that before choosing an alternative option, members must understand their current health situation, realistically assess the risks they will bear and how these will be impacted by the change – and make provisions accordingly.

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