Medical Planning

Here are a few Important things to know about Medical Aid and overall Medical Planning

Finding the right medical scheme for you and your family can feel like looking for a needle in a haystack. There are a variety of schemes out there with a variety of offerings and all have a purpose and great benefits for different users, BUT, which is best fit for you and your family?

The challenge here is to be able to evaluate each scheme and all of its options and benefits and be able to compare as best possible “like for like” and then make your choice.

So, how do you start...

The most important aspect to remember here is, you are looking for something that suites you and your families needs, not the other way around.

Firstly, what exactly is Medical Aid and how does it work.

South Africa has a dual health system consisting of public and private ​providers. Public medical services are provided by the government and generally used by the general population, while Private hospitals and healthcare services are used mostly by members of medical schemes or those able to pay for these services out of their own pocket.

​Medical aids are regulated by the Medical Schemes Act (1998).

What is the purpose of medical aid?

In Layman's terms,the purpose of a medical aid is to ensure that you are able to pay for treatment received from ​either a GP or specialist, or while in hospital.

It is very important to “insure” your health. Accidents can happen and you and your family’s health is unpredictable. If you cannot afford comprehensive cover, at least a basic hospital plan is recommended.

So, how do you choose a scheme that best suites you & your family?

Here are 7 checks to ensure you choose the right scheme:

​1 - Affordability:

  • What can you afford to spend on medical premiums each month? Remember, this is a very important aspect of your families planning so be reasonable but be realistic.
  • What are your families medical needs?
  • Be aware of changes and change your plan accordingly.

2 - Strength of the scheme:

  • Make sure that you join a scheme that is financially stable and is not going to have excessive premium increases and is reliable and consistent with regards to claim payments.

3 - Administration and Service:

  • Check to make sure that the scheme you join has a record for good service and administration. You don’t want to be fighting with your scheme every time you use your medical aid.

4 - Understand your In-Hospital benefits, exclusions and co payments:

  • You need to ensure, before you join a scheme, what the cover is that each scheme offers you. More specifically, what percentage cover do they offer based on the “Normal Medical Scheme Rate”? Is it 100% or 150% or up to 300%. Are you going to have to make co-payments based on what your services provider charges? Also be aware of what exclusions are made on the scheme such as joint replacement and neck and back operations.

5 - Understand your Out-of-Hospital Cover:

  • These days, most options in the market place work with a “savings plan”. Basically what happens here is that you are able to use this savings allocation immediately, but once this savings amount has been depleted, you will be required to pay for services directly from your pocket. Some options allow for an “above threshold” offering which can be useful if your costs and claims are high. Others have specific networks which are offered which allow the user unlimited doctor and dentist visits based on the plan.

6 - Chronic medication:

  • If you or anyone in your family has a chronic condition, and requires chronic medication, please ensure that the option and scheme you choose covers both the condition as well as the specific medication you require.

7 - Oncology, Dialysis and HIV:

  • It is important to make sure how the scheme and option cover oncology, dialysis and HIV. Most schemes have specific benefit programs for these conditions, which offer good cover, but it is important to make sure exactly what that cover is.

What Scheme choices do you have?

There are currently approximately 34 schemes open to the public at this point. There are however approximately 84 registered medical schemes in South Africa. Within these 34 odd open schemes, there are approximately 177 different options to choose from. This certainly gives one choice, but maybe just a bit too much to take in all at once.

The 10 Biggest schemes (in alphabetical order)

  • BESTmed
  • Bonitas Medical Fund
  • DiscoveryHealth
  • Fedhealth
  • Liberty Medical Scheme
  • Medihelp
  • Medshield Medical Scheme
  • Momentum
  • Oxygen

​Not that bigger is always better, this list does give you an idea of who the players in the market are. You can then do some research on the companies which you feel you would possibly like to deal with.

Scheme Options..

All scheme options are based on 2 primary types. These being:

1 - Traditional Plans: ​These plans cover almost all medical expenses (subject to the rules of the individual scheme) and include benefits for in-hospital and day-to-day expenses.

2 - Hospital Plans and Hospital with Savings: ​These plans cover expenses incurred while in hospital however you are responsible for your own day-to-day medical expenses either via your savings plan or directly from your pocket. These plans are generally more cost effective and are widely available.

The main differences between different medical aids, and options within them, is the cover provided with regard to specialists and other suppliers while you are in hospital.

The Department of Health has published specific rules and tariffs for specific health services and procedures performed in or out of hospital. These tariffs for the Council for Medical Schemes are called the National Health Reference Price List or NHRPL. They are only a guideline for specialists and anesthetists to follow when they charge you for a specific procedure performed in hospital. Most medical providers charge a far higher fee than this rate. Should the specialist or anesthetist charge you 300%, he is actually charging you three times more than the guide price as per the National Health Reference Price List.

Need some help?

If you would like more guidance and help with choosing the right scheme and options for yourself and your family, we would be very happy to assist you.

Please send us a message by clicking the button below and we will be in contact with you shortly.

Please know that your details and communication with us will be kept confidential at all times.