Many medical aid members find it hard to understand their benefits and how best to use them. For this reason, trying to compare options and schemes can be virtually impossible for the layman. According to Coastal Head of Healthcare for Alexander Forbes Health, Victor Crouser, knowing a little more about how schemes operate could help consumers make an informed choice about which option is most appropriate for them and their family.

Crouser has the following tips to help members navigate their way through medical aid territory:

The Law

Medical aids are regulated by the Medical Schemes Act of 1998 and the Council for Medical Schemes has a responsibility to ensure compliance with the Act. The Council’s website is www.medicalschemes.com and one can find useful information regarding the legal aspects and management of Medical Schemes. The Council for Medical Schemes also rules on disputes between members and their medical aids.

Who runs the Scheme

Each medical scheme must have a Board of Trustees who manage and control the Scheme affairs, complete with a set of rules which members are entitled to a copy of. As a member you are entitled to attend the Annual General Meeting of the Scheme and you can vote for trustees. Usually a medical scheme appoints a separate administrator who handles matters such as claim payments, hospital authorisations, and other administrative duties.

Plan options

Medical schemes have a number of different options and these differ according to the benefits on offer and the contribution payable. Contributions may vary according to family size and make-up, as well as income. It is important to know if your option requires you to use certain providers, as using a doctor or provider outside of the network could result in you having to pay in for the bill. You are allowed to change your selected option on a yearly basis, usually in January.

Hospitalisation cover

Some options require you to only use specific hospitals for planned treatment and this cover may pay at certain rates or have an overall limit. Members are usually required to notify the scheme beforehand for planned hospitalisation and are provided with an ‘authorisation number’ confirming that the procedure will be covered at the option rate. However, beware – the authorisation will only cover at the scheme rate of payment and many providers (for e.g. specialists and anaesthetists) who treat you in hospital may charge in excess of this payment. This bill then becomes your responsibility. Be sure to check prior to your procedure what the treating specialists and anaesthetist charges. If a quote is obtained, your scheme will usually be able to tell you upfront what will be paid.

Out of hospital cover

Day to day benefits (such as GP visits, optical benefits or medication) are covered by some options. These may be covered by a savings account or in some cases by a set scheme benefit. Always ensure that you are aware of what benefits and amounts are available to you, as well as the rate being charged – failure to do this may result in a co-payment.

Prescribed Minimum Benefits

The Act sets out certain Prescribed Minimum Benefits (PMBs) which all schemes have to pay for, regardless of which option you are on.  These PMBs cover various serious conditions and it is important that you review the PMBs if you suffer from any condition or expect to have any treatment. The scheme is entitled to apply their own rules to treatment of the PMBs and you should contact them for more advice on claiming for these. The Council for Medical Schemes website also has an FAQ document that helps educate members about their rights.

Chronic conditions

Chronic conditions are usually described in layman’s terms as potentially life threatening conditions where on-going medication is required. The PMBs set out 25 chronic conditions that must be covered by the scheme within set guidelines. The more common of these include asthma, high cholesterol, high blood pressure and diabetes. In these instances, the scheme will have to pay for certain medications as well as certain treatment, which may include blood tests and doctor visits. It is important to register for these conditions as this will then not affect your other day to day benefits. It is also important to know that the scheme may only pay certain medication amounts or for specific medications, so you should try and get your doctor to prescribe these so that you do not have a co-payment.

Rates of payment

Many members believe that their medical scheme should cover the full cost of what the doctor charges and are often shocked to find out that this is not the case. Providers are allowed to charge at different rates, but the scheme option that you are on will pay only at a specified rate. Beware of misunderstanding the often-used ‘100% of Scheme tariff/rate’. This does not mean that your healthcare provider will be paid in full, as they may charge substantially more than this scheme rate. Negotiate with your doctor to ensure that you are getting the best possible rate.

Negotiate with providers

Many providers are reasonable and are prepared to negotiate their charges up front if members are open and honest. However, they are naturally reluctant to do so when members come to them later, once they have found out that the scheme has not covered the full bill. It is therefore better to discuss the financial situation with your provider upfront, even though this may make you feel slightly uncomfortable. Remember like you, the provider has certain expenses they need to cover, but most are reasonable and aim to ensure that you receive good treatment. If they realise that you are concerned about finances, they may try to find more cost effective, but still appropriate treatment to aid you, or consider dropping their fees slightly.

Appropriate cover

Ensure that your health cover is appropriate and adequate for your changing needs as you journey through the various life stages. It is a good idea to use the services of an independent specialist healthcare advisor or broker who has knowledge on various healthcare solutions such as medical schemes, gap products, and other healthcare products. This professional can give you sound advice on which schemes and options to join, and has a responsibility to assist you in making a decision on a yearly basis as your healthcare needs change. They should assist you when it comes to challenging the schemes if payment has not been made, and if necessary guide you on the best way to take up your dispute with the Scheme or elevate the case to the Council for Medical Schemes.

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