Know your medical aid options

By Letitia Watson
16 November 2017
PHOTO: Gallo Images/Getty Images

PHOTO: Gallo Images/Getty Images

Hospital plans, comprehensive cover, network options…find out what’s the best medical insurance for you.

Medical aid members have until 15 December to change their benefit options.

Your choices will depend on your and your family’s health, how many members are covered and what you can afford. We look at medical aids’ general options and how net- work plans can save you money.

Hospital plans

Quick facts

  • These plans generally cover all in-hospital costs and certain out-of-hospital costs such as scans and chronic medication.
  • You’re also covered for prescribed minimum benefits (PMBs). This includes the diagnosis, treatment and care of conditions like diabetes, certain types of cancer, emergencies and certain chronic medication. Go to medicalschemes.com for a full list of PMBs.

You should know

  • Hospital costs aren’t always fully covered – specialist who treat you in hospital might charge more than the medical aid payment rate. The member then has to pay the difference.
  • Certain procedures – such as certain scans, gastroscopies and wisdom teeth removal – might require a co-payment.
  • Members are liable for medical expenses incurred out of hospital or that aren’t covered by their medical savings plan. If, for instance, you don’t have a medical savings plan, you have to pay for GP visits, X-rays, pathological tests or medication received out of hospital. This also applies if your savings plan has been depleted.

How to save

Consider getting a hospital plan that has a network option. Medical aids negotiate tariffs with private hospitals in order to limit costs.

The hospitals are then part of that particular medical aid’s network of hospitals. By changing to a network hospital plan you can save money without sacrificing benefits.

For example, Momentum's Custom Any Hospital Plan costs R4 336 a month for two adults and two children.

The network version, the Custom Associated Hospitals Plan, costs R3 367 for this family – a monthly difference of R969, says Karin Andrea of Optivest Health Solutions.

Who can benefit from a hospital plan?

  • Young, healthy members who don’t have many day-to-day medical expenses are usually happy with just a hospital plan.
  • Those who are able to afford to pay for day-to-day medical expenses but want to protect themselves against large medical expenses such as hospitalisation.

Ask a medical broker to compare various options for you.

Comprehensive cover

Quick facts

  • Comprehensive medical cover generally covers day-to-day out-of-hospital expenses such as GP visits, prescription medicine, dentistry, x-rays, pathological tests and hospital expenses. It also covers PMBs.
  • Each scheme offers various comprehensive packages. The greater the premium, the more comprehensive the cover.

How to save

Consider the network option. For example, it costs R5 806 a month for two adults and two children on the Medihelp Dimension Prime 3 Network, a network plan; while on the Dimension Prime 3 plan it costs R7 146 a month. The difference is R1 440.

When is comprehensive cover a good choice?

  • It works well for people with specific medical conditions or chronic ailments that require expensive treatment.
  • If your day-to-day medical expenses are more than you budget for, it's a good option.
  • It’s generally also suited to older people and families with small children who have a lot of medical expenses.

Reasons why members sometimes have to make co-payments

  • Specialists’ fees for in-hospital treatment and procedures might be more than medical aid tariffs. Members often take out gap cover insurance to cover the shortfall, Andrea says. Premiums are R180 to R400 a month per family, depending on the amount of cover.
  • Medical aids require co-payments for certain procedures such as gastroscopies or wisdom-tooth removal. Gap cover usually covers this.
  • Doctors’ and specialists’ out- of-hospital consultation fees might be more than your medical aid’s tariff structure, in which case you have to pay the difference from your own pocket.
  • If dentistry or optometry costs are more than the medical aid benefit, you pay the difference.
  • If you don't get your chronic medication from your medical aid’s preferred supplier, or you use medication that’s not on your scheme’s list of approved medications, you pay the difference in price. A generic version of the medication can cost less.
  • If you’ve reached your fund limit and/or your savings account has been exhausted, you have to pay all other medical costs yourself.
Read more on:    sick  |  medical aid  |  hospital

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