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It’s that time of year again, when medical aid schemes announce their benefit changes and costs for the year ahead. Given that medical aid costs are escalating faster than inflation, it can be tempting to look for ways to save. But it’s important to properly consider your circumstances and your health before ticking the box for the least expensive option.

What’s expected this year?

The expected average increase to be announced by medical aid schemes this year is between 8% and 10%, compared to inflation of around 4.9%. Due to rising costs, many medical aids are responding by not increasing certain benefits (e.g. oncology), so be sure to look at any benefit changes and compare exclusions.

Select an option that suits your needs

If you selected a hospital plan when you were young and single, and have not changed your plan since then, a detailed review may be long overdue. Most people think they will be able to fund the costs of an occasional doctor’s visit themselves. However, when you get seriously ill, require an out-of-hospital procedure, or have multiple family members getting sick at the same time, you may find yourself having to fund medical costs on credit. If you are not a member of a medical aid at all, the consequences could be devastating.

How do you choose the right plan?

The main determinant should be your medical needs, and it’s important to have a good understanding of what benefits are covered by which options and on which medical schemes. Affordability is important when it comes to selecting the right fit – but it should not be the only consideration.

Medical aid 101

  • Most medical aids will cover in-hospital costs (that is, when you are admitted to hospital) within certain limits. However, it does not mean that they cover all costs of being in hospital. Make sure you understand exactly what they do and don’t cover.
  • All members are covered for Prescribed Minimum Benefits (PMBs), which include 270 hospital procedures and 26 chronic conditions identified by law. Most of the common chronic illnesses (e.g. hypertension, cholesterol, asthma, diabetes) are covered via PMBs. Note that medical schemes are allowed to stipulate that members must use the scheme’s designated service providers (DSPs) to receive ‘at cost in full’ cover.
  • Beyond this, the detail will depend on the specific option selected:

o Most schemes cover additional chronic diseases on their more comprehensive options. Investigate which options, on which schemes, provide the cover you require.

o Medical schemes may limit what they pay in the case of serious illnesses, like cancer, mental illness or, for example, pregnancy (unless they qualify under the PMBs). In the first case, they may not pay for certain drugs, and in the latter case they may only pay for a certain number of scans and doctors’ visits.

o Minor procedures that do not require staying in hospital overnight are categorised as ‘out-of-hospital procedures’ by medical aid schemes and are therefore not covered under in-hospital costs. Be sure to check how your plan handles these costs.

  • Day-to-day benefits cover other expenses typically not covered in terms of any of the other categories, for example GP consultations, medication, optometry, radiology and pathology.

Now is your chance to review your choice

Members of all medical aids have an opportunity to change their option annually at this time of year. If you are considering changing schemes, be sure to clarify whether any waiting periods would apply before making the leap.

Get help if you need it

The right choice for you is the one that suits your medical needs and your pocket. If you’re in any doubt, consult a medical aid consultant or broker. They will be able to provide guidance on the right option for your circumstances, at no additional cost to you.

By: Shreekanth Sing, technical legal adviser at PSG Wealth