Consider this before choosing a medical scheme

The two most important factors to consider are your health needs and your budget.

It is very important that you choose an option which offers benefits to cover any health condition you or your family may have. For instance, if you know that you need spectacles and would struggle to afford to buy them out of pocket, then you need to choose a medical scheme option with enough optical benefits to cover regular eye tests and new spectacles/contact lenses when necessary.Another important consideration is whether to select an option which covers you primarily for catastrophic events, like hospitalisation and serious illnesses, and offers limited cover for day-to-day benefits, or whether to select a more comprehensive (and often more costly) option with rich day-to-day benefits as well as catastrophic cover. Important to remember that even if an option is primarily a hospital plan, it must by law, cover the Prescribed Minimum Benefits (PMB), 27 chronic conditions and all emergency treatment.

Click here to see the list of PMB and chronic conditions.

Many medical schemes contract with select groups of doctors and hospitals to ensure that their members are charged within the scheme rates and are provided with health services that are efficient and of a high standard. These doctors and hospitals are generally referred to as Designated Service Providers (DSP). Options which make use of DSPs are generally less costly than those that allow freedom of choice of healthcare provider. If you select a DSP option, it is important that you know and accept your obligation to use a doctor or hospital from the list of DSPs. It is also important that you check the list of DSPs so that you know which GP, specialist or hospital you would access when and if you need to. This obviously excludes cases where emergency treatment is necessary.

It is very important to check the level at which your chosen benefit option pays, e.g. 100%, 200%, 300% of tariff. This means that if your scheme pays at 100% of the tariff specified in its rules, and the doctor charges 200%, you may have to co-pay the remaining 100%. Generally speaking, the more comprehensive the option, the higher the rate at which the scheme will pay.Note, however, that this does not apply to the list of PMBs which must be paid in full by the scheme. But remember that while medical schemes must cover the PMB in full, members are expected to use the DSP network of providers and facilities to receive these benefits with no co-payments, except where it’s impossible to do so.