Guide to maximising your bang for your buck from your medical aid

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Most medical aids have launched their benefits and premium contributions for 2017 and, as in the past, the increases passed on to members are double figures, which outstrip inflation.

Bear in mind that your actual increase may be somewhat different because often these are weighted, vary from option to option or even from dependant to dependant.

The medical aid landscape can be tricky to navigate. So now, more than ever, is the time to learn how to ‘box smart’ to ensure that you maximise the value you derive from your medical scheme benefits. Dr Bobby Ramasia, Principal Officer of Bonitas Medical Fund, provides some insight into maximising the benefits on your chosen medical aid.

Understand your benefits

Take the time to read the information sent to you by the scheme and/or your broker. If you have access to information sessions at your place of work, or have a consultant who visits your workplace, attend the sessions to get a better understanding.

Getting the best out of your hospital cover:

  • If your scheme has appointed a Designated Service Provider (DSP) network for hospitals, you will usually pay a lower monthly contribution in exchange for using a hospital from this network for planned procedures In the same manner, if your scheme has an arrangement in place for doctors and specialists, there will usually be an incentive (full cover by the scheme) for using ‘these’ providers. The penalty for using providers not contracted with the scheme is usually the payment of shortfalls or co-payments. For planned procedures, it’s also worth checking with your scheme if you will obtain better cover by using contracted providers or having the procedure performed in the doctor’s rooms or day clinic, where possible.
  • If you are going to be admitted to hospital for a planned procedure, always check with your scheme, at authorisation stage, if there are any co-payments or sub-limits that will apply. An example here is for joint replacements, where most schemes have specified sub-limits if you do not use their DSP.

Chronic illness benefits:

In terms of the Medical Schemes Act, there are 26 common chronic illnesses which all options on all schemes are required to cover for medication and treatment. However, here too, schemes have the ability to apply measures designed to contain costs.

  • Almost all options on all medical schemes apply a medicine formulary. This is a list of drugs which the scheme will cover in full. If you use medication that is not on the scheme’s formulary, you will be liable for the difference in cost. So it is best to discuss the formulary medication with your doctor to see if this is appropriate for you.
  • The schemes can also specify that you obtain your medication from DSP pharmacies. Check to see if you are able to use the scheme’s DSP – if there are none close to you, most schemes also designate a courier pharmacy which will deliver the medication to you at a preferred address.

So, the golden rule for chronic illness benefits is to try to utilise the medication on your scheme’s formulary and to obtain this from a specified pharmacy.

Many medical schemes also cover additional chronic illnesses – although this is usually from the more expensive options –if your particular condition is not covered on your current option it is worth further investigation. It’s important to understand that this cover is at the scheme’s discretion and the additional conditions covered vary from scheme to scheme.

Know your rights!

In terms of a High Court ruling, Medical Schemes are obliged to meet the cost of in-hospital Prescribed Minimum Benefit procedures at cost, in full. Make sure you know what ‘in full’ means – so you don’t get any surprises. So if you have been admitted to hospital check with your doctor if it’s for one of these procedures. If so, as a general rule, you shouldn’t be saddled with any shortfalls – so ask for your broker’s/consultant’s assistance if you are!

Why you might have co-payments

A medical aid co-payment is a fee that the member is liable for when making use of certain medical services. The medical aid would not cover 100% of the costs and the member would have to pay for a certain percentage of the medical service before the medical aid pays their portion.

These co-payments usually apply to specialist or elective medical procedures. This will differ from one medical aid scheme to another. It is one of the reasons why you should always do thorough research before deciding which medical aid scheme is the best option for you. The ideal option would of course be the one that does not require many or any co-payments from the member.

If your benefits and/or savings were exhausted before the end of the year and had to pay out-of-pocket for some medical expenses; it might save you money if you upgrade to a richer plan with more benefits albeit at a higher contribution amount. Conversely, if you are young, healthy and generally did not utilise your benefits and/or savings, it may be prudent to downgrade to a cheaper medical aid option.

Talk to your providers!

Talk to your doctor/specialist before being admitted to hospital for a planned procedure. Check what they are going to be charging and what your scheme will cover. If there is a large difference don’t be afraid to approach your doctor to see if they are prepared to adjust their fee, especially if you could afford to pay upfront.

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