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How to read and understand your medical aid to avoid paying for benefits you will never use

Article written by Viwe Ndongeni-Ntlebi (Bonitas)

Everyone needs some form of medical aid cover. Few of us could afford the costs of long hospital stays or care for serious injuries, surgery, or chronic illnesses.

Medical schemes help us finance life’s curveballs when we can’t do it alone. It’s advisable to evaluate your medical aid coverage each year to make sure you have adequate cover for your needs or for any changes in your health.

What must you look for when reading the benefits of a medical aid scheme?

Lee Callakoppen, principal officer of Bonitas, says you should read the scheme information carefully and if you have a broker, discuss your cover with them. Benefits vary from plan to plan and it’s important to establish what is and isn’t covered. The following factors should be taken into consideration:

  • Establish what additional risk benefits might be available that can potentially provide savings on day-to-day expenses. Once you understand what is on offer, including any managed care options to manage severe chronic conditions like cancer, diabetes and HIV/Aids, you can make an informed comparison and decision.
  • Ask what supplementary benefits might be available to you that can also potentially save significant day-to-day expenses. These could include preventative care benefits, from basic screenings (blood pressure, cholesterol, blood sugar and body mass index measurements) to mammograms, pap smears and prostate testing. In some cases, this extends to maternity programmes, dental check-ups, flu vaccinations and more
  • Ask about the savings and day-to-day benefits being offered including out-of-hospital expenses such as GP consultations, over-the-counter medicine, dentistry and optometry
  • Check whether you must be referred to a specialist by your GP and whether your medical aid offers additional GP consultations after you have exhausted your day-to-day benefits.
  • Most schemes have started to embrace technology and virtual care. Check that the scheme and plan you are considering allows you to access your benefits and medical information 24/7.
  • Find out about the scheme’s rules in terms of waiting periods and exclusions. If you are required to use a specific GP, hospital network or Designated Service Provider (DSPs) with whom the scheme has negotiated special rates, check the designated network in your area before making a final decision.

Medical savings are a fixed amount a medical scheme gives you at the beginning of the year. There are ways to maximise your savings but first you need to know what your annual allocation is.

How do you know if you are paying for benefits that your lifestyle does not need or you will never use?

According to the Fedhealth team, to protect the consumer, the medical aid industry is highly regulated by the Council for Medical Schemes (CMS) as well as by legislation. “This means that medical schemes don’t simply have free reign when it comes to designing their benefits and limits, and also have to cover certain conditions called Prescribed Minimum Benefits or PMBs – regardless of the option the member chooses.

“To make sure you take out a plan that is most suited to your needs, you need to do your own homework when you choose a medical aid. Read through the option guide properly before you sign up and don’t be scared to ask questions.

“For example: You really don’t need the most expensive medical aid plan with lots of cover for chronic medication if you are young and healthy. But, on the other hand, if you are planning to get pregnant, or have small kids, you will need a plan with maternity and childhood benefits, as well as day-to-day benefits for those trips to the GP,” the medical scheme advises.

Callakoppen notes that most schemes suggest ways to maximise your benefits, including:

  • Use Designated Service Providers (DSPs) or networks.
  • Use generic medications which are cheaper.
  • Utilise the managed care benefits which are covered by the risk portion of your contribution, not your savings.
  • Go virtual – virtual consultations are cheaper, so use these where possible.

In the event of hospitalisation, ensure you get pre-authorisation and a quote, make sure your doctor has filled in the correct ICD-10 codes and choose a network hospital where possible.

What is gap cover and what are some of the benefits of taking gap cover in the long run?

In essence, gap cover is a short-term insurance product that gives extra financial protection for those who already have medical aid.

Fedhealth says, “It helps to cover some of the shortfalls between what your medical scheme will pay and the rates charged by in-hospital medical specialists.

“The high cost of specialist treatments and above-inflation increases mean that more people are at risk of being excluded from quality medical care.”

“Gap cover gives you the freedom to choose whichever doctor or specialist will give you the best care, regardless of your medical scheme or rates.”

Bottom line: For a reasonable amount every month, gap cover can protect you from financial ruin by making the funds available so you can cover shortfalls between what your medical aid pays, and what specialists charge in-hospital.

This article first appeared in the Health digital magazine. Read more here.

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