5 Questions to ask when choosing a medical scheme

By Marlize De Villiers

Deciding on the best medical aid policy for you and your family is a mammoth task. Your monthly instalment will constitute a significant part of your budget, and, with healthcare costs skyrocketing, the wrong choice could be costly.

There are 18 open medical schemes in South Africa of the 78 schemes in total, each offering a variety of tiers and plans. Sifting through the information to make meaningful comparisons can be overwhelming.

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The following questions can assist you to make the correct decision.

1. Where should you start?

Medical aid plans are as unique as the people who utilise them. It’s important to start by assessing your current situation.

Consider your demographics, such as family size, member ages, and specific healthcare needs. Gareth Collier, director at Crue Invest (Pty) Ltd, suggests making a list of pre-existing conditions or ailments, along with any chronic medication or treatment used by you or your family.

Collier recommends regular review of your medical status, as plan subscriptions can be changed annually.

2. When is the right time to join a scheme?

Financial pressure is rising, with no indication of respite. The general guideline is that medical aid premiums should not exceed 10% of your monthly expenses – but this remains a substantial investment. It might be tempting to forgo or cancel this obligation, in exchange for some cashflow relief.

Susan Brits, regional manager at Profmed, notes that this decision could have major financial implications. Besides the risk of unforeseen medical expenses, or inadequate public health care, late joiner penalties apply to applicants who are aged 35 years or older, or where members have had a break in cover of more than three months.

The penalties range from 5% to a whopping 75% of the risk contribution to the scheme – and they apply for the rest of the member’s life.

Chronic conditions, which increase with age, will incur exclusions and waiting periods. “One should join a medical scheme as early as possible, to avoid waiting periods and higher premiums”, Brits advises.

3. Are you getting value for your money?

Value for money should not be confused with lower premiums. Co-payments, penalty costs, and limits on in-hospital cover should be considered, to determine whether a medical scheme offers value for the money you will pay.

According to Joanne Stroebel, director at JST Consulting (Pty) Ltd, preventative benefits, such as dental check-ups, add value in the short and long term. “Early detection and treatment of medical risk factors will save money and ensure better outcomes,” she explains.

4. What is your medical expense budget?

Collier recommends a rigorous budgeting exercise when starting the selection process. To make an informed decision, you need a realistic picture of your medical expenses.

While a hospital plan might offer a lower instalment, actual day-to-day or chronic expenses could justify upgrading to a more comprehensive option.

Collier advises against simply opting for the cheapest premium, because the risk is that your cover will be inadequate.

The table below compares three open schemes and one restricted scheme, based on two adults and two children, without network hospital limitations.

 

Discovery (open)

Bonitas (open)

Momentum (open)

Profmed (restricted)

Plan

Essential Core

BonEssential

Custom

ProActive

Monthly contribution

R5,692

R4,780

R7,275

R5,814

Annual oncology benefit

R200,000

PMB* only

R300,000

R233,078 – thereafter PMB legislation applies

Annual maternity out-of-hospital consultations – GP, gynaecologist or midwife

Up to 8 visits

6 visits

12 visits

None

Maximum age for full-time student dependents paying child rates

21 years

24 years

21 years

28 years

*Prescribed Minimum Benefits (PMBs) are benefits that medical schemes must extend to their members, regardless of the plan or option they have selected.

5. Do you need specialist advice?

Even after researching carefully, the information can be overwhelming. While online comparisons can assist, they tend to include the main medical schemes only.

According to Collier, specialist advice will ensure that you find the plan with benefits best suited to your specific needs.

Given the expense that medical schemes represent - and the potential costliness of not having cover in the event of an emergency - an independent healthcare advisor may be the safest option for making the best decision for you and your family.

If you’re short on cash and you need to settle hospital bills, you can apply for a personal loan here.

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