What your medical aid can do for you when you’re going into hospital

Medical aid members can save themselves significant amounts of time, money and effort if they ask their medical aids the right questions, especially ahead of planned procedures.

The Council for Medical Schemes (CMS) concurs that members’ lack of understanding regarding their medical aid plans is one of the biggest reasons for members’ unhappiness regarding their level of benefits.

The CMS recently told Parliament that the number of complaints from medical aid members has increased by 1 017, to 4536 or 29% during 2017-2018, compared to last year.

This is in line with our experience as healthcare consultants to various businesses: unfortunately the majority of members do not attend medical aid presentations nor examine their medical aid policy with enough care, even when they are aware of an upcoming procedure or specific treatment within the year. Members then realise – too late – that their medical aids do not cover certain procedures or costs.

Medical aid members need to change their behaviour towards their schemes and realise the onus is on them to establish the extent of cover they qualify for, ahead of their procedure.

Whilst members may only change their plan, within the same scheme, once per year, its advised that they can still protect themselves against unexpected expenses in the event of planned procedures and treatments.

Generally speaking, members should ask their medical aid or healthcare consultant the following ten questions to get a better grasp of their cover, and so avoid unexpected bills.

1) What type of plan am I on? 

Firstly, establish what type of plan you contribute to and communicate this to your doctor or specialist. This will give them an indication of the type of items or treatment you will be covered for, and whether this includes in and out of hospital cover.

2) What level of cover do I get?

In addition to knowing which plan you are on, it is also important to understanding what level of cover – ranging from 80% to 300% – your plan offers for the various line items of your procedure. Importantly, if your medical aid covers 100% of an item, this does not necessarily mean it pays for the entire cost of the item.

Medical schemes have set rates for treatments and consultations (representing 100% or the Scheme Rate), though practitioners and hospitals often charge fees that are higher than these rates, sometimes up to or even higher than 500%. It is therefore important to verify which rate your treatment and consultations are charged at, and whether your plan covers the entire cost. 

3) Am I responsible for part of the costs of my treatment?

Once you know what level of cover your plan offers, find out whether you need to pay for part of your procedure and what this cost would be, so that you are prepared for any co-payments which may be required prior to admission or any bills that follow.

4) Does my gap policy cover the shortfall of my medical aid? 

If you have gap cover, do not assume that this will necessary make up for the entire shortfall that your medical aid does not pay. Gap cover policies differ in scope and may only cover up to a certain level or multiple of the scheme rate. Members need to examine these policies to understand what, and at which rate, their gap policies will foot the bill.

Furthermore: members should be cognisant of the demarcation rules introduced by National Treasury last year, that limit gap cover to R150 000 per member per year. 

5) Does my hospital cash-back plan cover the shortfall of my medical aid?

Similarly to gap cover policies, members should remember that the demarcation rules limit hospital cash-back pay-outs to R3 000 per day, or a lump sum of R20 000 per year. This can seriously affect a member’s expectation of cover for their hospital bills.

6) Is my procedure covered by prescribed minimum benefits (PMB)? 

All medical aids are required to cover the entire cost related to PMBs, which are a set of 270 conditions defined in the Medical Schemes Act. If your procedure is one of these, find out which designated service provider(s) – these are a medical aid’s preferred doctor, hospital, etc. for various PMBs – you will be required to make use of to qualify for unlimited cover. If you are not using the designated service provider, be prepared to cover the additional costs yourself.

7) Do I have to go to a network hospital?

Depending on the type of plan you are on, your medical aid may only cover treatments at hospitals which fall within their network. You should also determine whether your preferred or referred surgeon operates at the network hospital.

8) Do I have to use a certain specialist covered by my medical aid’s network?

Medical aids often have selected doctors and surgeons in their networks, these are covered at the scheme’s full rate. If your practitioner is not on your medical aid’s network, you may be liable for payment of a portion of the bill, depending on the doctor’s rate. 

9) Will I need an anaesthetist?

This may seem like a small item, but the cost of an anaesthetist is often quite substantial, leaving a hefty portion for your back pocket, if this is not entirely covered by the medical aid. Find out whether you will require an anaesthetist and whether they are in your medical aid’s network, as well as the level of cover you will receive.

10) Will I need recovery treatment?

Lastly, find out whether you will need after-procedure treatment, such as a physiotherapist, and whether your medical aid covers all or part of this cost.

Members contribute to a medical aid to manage their healthcare expenses and avoid having to pay for costly procedures out of their own pocket. Similarly, medical aids need to constantly manage healthcare costs ensuring they remain viable entities and provide suitable and sustainable benefits to members. Changes to plans and benefit levels is a constant within this environment, which means members have to be more vigilant in ensuring that the level of cover provided by their plan continues to meet their requirements. Assistance from your professional healthcare consultant and your own diligent attention to changes within the medical aid environment are the only ways to ensure that your medical aid continues to do what you need it to.

Jill Larkan is the Head of Healthcare Consulting at financial advisory firm GTC.

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