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Overwhelmed by medical scheme benefit option choices?

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Overwhelmed by medical scheme benefit option choices?:

Healthcare consumers urged to carefully weigh their options for best value

Few people’s hearts leap with excitement at the prospect of reading and comparing the finer details of various medical scheme benefit options. This investment in time, however, will put you and your loved ones in good stead when the need for healthcare cover arises – a time none of us enjoy contemplating.

“In South Africa just over 18 percent of the population have medical scheme coverage, according to the most recent General Household Survey published by Statistics South Africa,” notes Mark Arnold, Principal Officer of Resolution Health Medical Scheme (Resolution Health).

The same survey found that more than 95 percent of South African households had at lease one cellphone. As is the case with weighing up the relative value and merits offered on different cellphone plans to match our mobile phone needs, Resolution Health encourages consumers to look carefully at the merits of different medical scheme benefit options to find the one that suits them best.”

“When choosing a cellphone contract a person is likely to consider what they want and need in terms of airtime, mobile data, and phone features and temper this to match what their budget can stretch to. Similarly, when choosing a benefit option for healthcare cover, it is important to ensure that your medical scheme is not only offering you affordable cover, but richness of benefits as well,” explains Arnold.

Understand what you are paying for:

With more than 80 medical schemes in South Africa, the coverage and costs of their benefit options vary widely and it is not uncommon to feel somewhat overwhelmed when faced with such an array of choices. This is all the more true because, as the main member you bear the responsibility of selecting an option that will cover your beneficiaries’ health needs as well as your own, if you opt to extend membership to your loved ones.

Arnold notes that it is often worth seeking advice from an objective healthcare intermediary or broker, who will be in a position to provide you with a broader perspective of what is on offer in the industry. However, when consulting a broker, ensure that he or she is accredited with the Council for Medical Schemes (CMS).

Do your homework – it will pay off in the long run:

“Invest some time in carefully going through the paperwork to ensure you understand what is on offer. Do not ever skip the fine print. While it may not make for riveting reading, it is imperative that you are familiar with all the details of what you are signing up for. Knowing what you have bought will ensure that you are not left red-faced and out of pocket for costs that may not be covered on the option you select,” Arnold advises.

“Many individuals focus on affordability and only scan their benefits quickly. Remember, you need to make sure you have cover for your specific needs. While budget is important, your health – particularly as you increase the size of your family and in later years get older – must take priority where possible,” says Arnold.

As in the analogy of the cellphone contract, you may want to find a cheap deal but, when examining what the contract entitles you to, find that it may fall well short of your needs, or come with so many restrictions attached that it is not worth your while.

Prescribed minimum benefits – what exactly are they? :

By law, medical schemes must cover the treatment of 270 medical conditions, known as Prescribed Minimum Benefits (PMBs). These include 25 chronic diseases defined in the Chronic Disease List, and all life threatening emergency conditions.

“If you spend some time familiarising yourself with the PMBs, this will assist to equip you with knowledge of the extent of coverage you can reasonably expect for chronic conditions. Remember, however, that PMBs are not a blank cheque and you may not be covered in full by default if you choose to use a healthcare service provider for your PMB treatment that is not contracted to your scheme,” Arnold elaborates.

“However, in the case of a life-threatening emergency you can use any provider, but only until you can be moved to a scheme-preferred provider.”

The costs:

With medical schemes, as with mobile phone contracts, you get what you pay for. Those who are price conscious should nevertheless ensure that their medical cover meets their minimum expectations every year.

“It should be noted that there are some major differences in the cover provided by medical schemes and insurance products. Again, read the small print and make sure that you are aware of all exclusions and limitations of the product. Carefully consider what real value the product offers.”

While affordability is a significant factor in choosing medical scheme cover, your choice should take into account the possibility that you or a member of your family may be faced with a serious health problem or need access to acute hospital care. “No one likes to think of such scenarios, but it is near impossible to predict when you may need more comprehensive cover for your medical care. You will certainly want to avoid a situation in which your cover is inadequate at a time when you or a loved one really requires it,” Arnold cautions.

Administration costs:

Find out what your scheme’s administration costs are. Medical schemes are either self-administered or run by a third party administrator such as Agility Global Health Solutions Africa.

Make sure the scheme you choose is well administered. If a scheme’s non-healthcare costs are high, this is an indication that they are spending less on your benefits and may signal less ‘bang for your buck’.

Average increases:

In addition, it is a good idea to enquire what the scheme’s average fee increases were over the past few years. Look at rand values, not just percentages, and be sure to check if there were any benefit cuts. It is well to be aware that some medical schemes may trim down their benefits to maintain fairly low annual increases. “The upshot of this for consumers, is that they risk having access to fewer benefits in the long run, even if their pockets feel some respite.”

Beware exclusion periods:

When you join a new medical scheme, you may be subject to a waiting period for certain treatments. Also, if you have a pre-existing medical condition, medical schemes are entitled to withhold cover for that particular condition for a defined period of time.

“It is extremely important to inform your new medical scheme of any pre-existing medical conditions when you join and enquire what consequence this has for your cover and treatment of that condition, and for how long. If you try to claim for a condition you failed to disclose, the scheme can refuse to cover that particular illness and may even decide to cancel your membership.”

Medical savings accounts:

In terms of the Medical Schemes Act, up to 25% of the members’ premiums can be set aside and put into savings accounts. The medical savings account (MSA) affords members a form of credit and ensures that these funds are not used to cross-subsidise other members.

“For members in good health, this may hold a certain appeal, however, once the savings account is depleted and members are forced to dip into their own pockets to fund their medical expenses they may be less enamoured with the arrangement.

“Remember, if a medical scheme member accumulates a credit balance in their MSA, they cannot draw the cash. This is only possible upon termination of membership of a medical scheme and on the proviso that another medical scheme with an MSA option is not joined,” says Arnold.

“My advice to healthcare consumers would be to weigh up the pros and cons of a medical savings account versus the security of allocated benefits in a traditional option.”

Keep your eye on the ball

“The healthcare market evolves every year, and so do our healthcare needs. For this reason, it is important to take stock of whether your healthcare option remains appropriate to your needs at the end of each year, and to make quite sure that the cover you are getting is the cover you really need,” Arnold concludes.

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Source: Port Elizabeth – MyPR.

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