2012 Peter Pyburn Choose a Medical Aid
How to Choose a Medical Aid!Medical aid is like oxygen: it only becomes a concern when you don't have it!
There can be nothing worse than being in private hospital, recovering from an illness or an accident, knowing you do not have a medical aid with which to pay a huge financial bill facing you. Medical providers may cure you, but only medical aid can cure your wallet!
Without a medical aid you can only look forward to the State Hospital treatment and that is a serious threat to your health!
A good medical aid means that you can rest assured knowing that your medical costs will be covered in all cases that require private hospitalisation and the right medical aid will give you access to high-quality medicines especially in the case of chronic long-term illnesses.
We have all heard of people being forced to use their life savings and sell their houses to foot costly hospital bills after a loved one was involved in a car accident or a natural disaster.
Discovering the right medical scheme and the appropriate medical plan needs a bit of research and shopping around. There are many variables you need to consider and it is highly recommended you use a broker.
Is it gym membership and movie tickets you want, or is it the actual medical cover that you will be receiving when you need it most that is important to you?
When you phone a call centre, do you want to deal with an administrator who deals with a number of medical aids just your scheme and do you want peace of mind your medical aid will be there for you tomorrow and the next day for as long as you may need it?
Here's a guide on what to look for when choosing a medical aid.
The main difference between medical aids and the options within them, has to do with the cover you have for specialists and other suppliers while you are in hospital. Every year medical aids and providers meet and determine a base cost for all treatments. This is known as the medical aid rate or NHRPL fee. Most private providers charge more than three times this rate, so if your medical aid pays medical aid rates you face a substantial shortfall in claims when using private providers!
You need to make sure you know what your scheme pays for claims - medical aid rates or private rates - as you will have to pay any difference in costs to your private providers.
So how do you cover a possible shortfall between what your medical aid pays and what your private providers may charge?First see if you can negotiate a lower charge with your provider.
As this is not always possible, you may need to consider a GapCover plan in addition to your medical aid.
A GapCover plan is designed to pay the difference between what your medical aid pays and private providers charge.
A Top Up plan is a positive add-on to your medical aid. In fact some members choose lower (and cheaper) options within their medical scheme and take a Top Up plan to reduce or eliminate self payment gaps in-hospital.
Many people feel medical aid is expensive and the benefits they receive are just not worth it.
If you are in this situation you need to consider switching to a hospital only or a network plan (lower contributions) and buying a Top Up plan to ensure private hospital cover.
Whatever you may do, never be without hospital cover!
Hospital cover plans offer cover whilst in-hospital only. As you are responsible for all your out of hospital costs (there is one hospital only plan that protects you against excess of day-to-day costs), the contribution is lower than other medical aid plans.
Full cover plans cover most medical expenses in and out of hospital, according to the rules of the plan you may join.
They also cover regular medical treatment and chronic conditions.
Always make sure that you understand the rules of your medical aid for what is not paid is as important as what is paid! All medical aids exclude certain treatments. Make sure you know what is excluded.
Remember, it is a medical aid not a medical aid paid!
Ask yourself these questions:
What can you afford? Do you use chronic medicine? Are you expecting to go to hospital in the near future?
Then choose the best medical scheme for your needs looking at the various benefits and limits on offer.
Consult my brokerage to assist you.
- Are you covered in-hospital?
- How is 24HR trauma casualty paid?
- Does the plan pay for post hospital treatments otr do these get paid from your savings?
- Check whether the scheme pays medical aid or private rates.
- Check the benefit limits and whether there are co-payments on claims.
Many schemes have co-payments (i.e. covered from your pocket) on certain procedures, like gastroscopies, laparoscopies, removal of wisdom teeth, colonoscopies and joint replacements.
The co-payments differ from scheme to scheme and also depend on whether the procedure is done in or out of hospital.
- You cannot know how much your hospital stay will cost, so you should consider a no overall annual limit scheme.
- Do you need a Top Up plan?
- Check the scheme's membership status and solvency ratio. This may avoid interim premium increases happening.
- Who administers the scheme? Paying a small service fee to your broker can avoid hours of call centre frustration.
- Make sure you know what out-patient benefits the scheme has. This is important when considering HIV or cancer treatment.
OUT OF HOSPITAL
- Will you suffer a waiting period?
- How does your scheme pay day-to-day claims?
Most medical aids offer " savings."
These are funds you are allocated at the beginning of the year with which to pay costs and any co-payments due.
These funds are pro-rated depending upon the month you join.
Some schemes will offer additional benefits once your savings are depleted, known as above a threshold cover.
- Network schemes force you to use specific providers. As a result their contributions are lower and treatments like GP visits and basic dentistry are generally and unlimited.
- Make sure a chronic condition is covered on the option you may want to join.
Medical aids pay for medicines that are on their lists.
Make sure your medicine is listed.
Get to know what your medical scheme offers. Read the fine print. It is your responsibility to know what it is you are buying.
I do not know your medical conditions or lifestyle and my function is merely to present various medical aid options to you.
Do not expect your scheme to pay everything when you have chosen a plan that has a degree of self insurance, like a hospital only plan.
Know your rights. There are certain conditions (PMB conditions) that medical aids at to cover.
Please consult the Council for Medical Schemes website.
Some schemes offer wellness-related benefits.
Most schemes offer a range of preventative care benefits in order you to remain healthy.
They offer cover for treatments such as flu injections, mammograms and prostate screening, blood pressure and cholesterol tests.
You need to investigate the value of these preventative care benefits, as they may aid in preventing future serious conditions developing.
Other schemes offer lifestyle reward programmes. The scheme incetivises you to keep healthy, but it does cost extra and you do need to use them in order to get rewards.
Vitality is the leading wellness programme.
Probably the most important action you can take is to use an accredited, knowledgeable healthcare broker like myself!Medical aids complicated products and the language used is not always understandable.
It pays to get professional advice.
All medical aids can add waiting periods. They consider your application and decide on your age and the answers to the medical questions.
A waiting period is the period during which you will not be covered for medical expenses incurred, even though you may be making contributions to the scheme.
There are 2 different waiting periods;
3-Month General Waiting Period during which a member is not entitled to claim any benefits - except hospital medical expenses as a result of an accident.
12-Month Condition Specific Waiting Period during which a member is not entitled to claim any benefits for a condition for which medical advice, diagnosis, care or treatment was recommended or received in the 12-months before the date on which membership was made. This includes pregnancy.
A waiting period will usually apply if;
I cannot confirm a waiting period until your application is underwritten.
- You have not been a member of a registered medical scheme for at least 2-years before joining the medical scheme or
- the break in membership between leaving your previous scheme and joining the new scheme is more than 3-months
- the change in medical schemes was not as a result of changing employment.
So, the sooner you send me the application, the sooner we can see the schemes decision!
LATE JOINER PENALTY
Any new member of a medical aid - older than 35 - is subject to one. You need to prove past years of membership NOT to have one imposed. Any lesser period will result in a penalty. Only once I know how many years you were on a medical aid, can I confirm any penalty.
You can provide either a Certificate of Membership from all past medical aids, or if you cannot, an affidavit attesting to membership form a Commissioner of Oaths with your application.
Whilst it is not for me to choose your plan, herewith some pointers...
- Your greatest risk lies with private hospital costs. So, if you want Private Hospital cover, you need a plan that pays at 300% of medical aid rates!
- And you must consider TOP UP cover if your plan does not pay 300% of medical aid rates!
To investigate some medical aids please GO HERE.
If you want to investigate one of the above medical aids, simply mail me the MEDICAL AID REQUEST FORM ON EACH MEDICAL AID PAGE and I will send you some options to consider.
Please use my services.An independent medical aid adviser. I promote many companies and can find a plan to suit your needs.
I am accredited with the Council of Medical Schemes and am in a position to give you comprehensive advice.
Interested? Then please contact or email me NOW!!
The last thing you need is a financial shortfall when you are trying to recover!
Especially if you are considering Medical Aid.