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Struggling to decide on your medical aid option for 2012?
 John Cranke John.Cranke@psgkcorporate.co.za |
Most medical schemes have launched their benefits and contributions for 2012. John Cranke, Regional Head, Coastal Region PSG Konsult Corporate dissects the changes and benefits for medical schemes for 2012 and offers some healthy advice about choosing a medical aid option.
An overview.
Increases for the schemes range from about 7% to 12%. The average increase, for the top 10 largest schemes, is about 9.5%. However, it's important not to blindly accept the average headline increase declared by your scheme for the following reasons:
- In many cases the increases have differed from option to option.
- In some cases the increases have also differed depending on your family configuration - with different increases declared for adult dependants and/or child dependents.
- Not all schemes offering salary bands (contribution dependent on salary) to determine contributions have increased these in line with salary inflation. This means you may be in for a surprise when you get your salary increase during the year.
It is imperative that you choose the best option to suit your needs (and, hopefully, your pockets!). Remember, the option can be changed annually (note the cut-off date) and, although it shouldn't be necessary to change your option every year, it is a good idea to review your benefits annually to ensure they remain appropriate. Therefore, as a point of departure, to read through the information provided by your Company's scheme or broker. However, the information can be overwhelming, so it may be best to seek the advice of your broker or consultant.
What is your Company's Medical Aid subsidy policy?
Medical Aid subsidy policies vary from company to company, and depending on the subsidy policy applied by your company, this will have a direct bearing on the portion of the contribution you pay, so ensure that you understand this as a point of departure.
Possible pitfalls when choosing the medical scheme option
Hospital cover required:
Does your option have Overall Annual Limits, or not? If so, are you comfortable with this? Medical schemes are obliged by law to cover you for Prescribed Minimum Benefits (PMB's), which stem mainly from life-threatening injuries or diseases. You may be required though, to use the scheme's Designated Service Provider if you/your family claim expenses up to the limit stipulated for your option or, in a worst case scenario, be denied on-going non-PMB benefits.
Do you understand:
- What the co-payments (and deductibles) on your option are?
- What reimbursement rate you enjoy for service providers in-hospital (e.g. doctors, specialists, anaesthetists)
- That 100% of the scheme rate may still mean the potential for significant shortfalls for in-hospital treatment, even if your admission has been authorised?
- That your scheme may have an arrangement with providers (contracted with the scheme) which will allow you to enjoy full cover. If so, are you happy to use them?
- That many schemes have entered into arrangements with specified hospital networks, which mean that if you use these you qualify for a discounted monthly contribution.
- That you can take out gap cover to cover the shortfalls and co-payments?
Chronic Illness Benefits.
In terms of the Medical Schemes Act, there are 27 chronic illnesses which all options on all schemes need to cover completely. However, the schemes can decide which medication they will cover in full (usually the generic) and which pharmacies you can use. Take note of this so you don't end up paying a co-payment.
More expensive medical scheme options cover additional chronic illnesses - so it will be worth your while to investigate this.
Day-to-day Benefits
Are you happy to be on a hospital plan, which only covers hospital admissions and the compulsory chronic illnesses, or do you also need additional out-of-hospital or day-to-day benefits?
Most members select options that offer them at least a component of day-to-day cover and a good way to determine what day-to-day cover you need would be to assess the history of your claims, then take into account any future expected expenses, and match this to a suitable option.
Many schemes are relying on cost containment measures such as prescribing provider networks including GP's and specialists. On these schemes using a non-network provider would result in restricted benefits and/or co-payments.
Also check your preventative care benefits (such as mammograms which cost around R900) to see if they are included in day-to-day benefits. Increasingly schemes are funding these separately, which can mean a substantial saving.
In addition to the above, some other ways to help stretch your day-to-day benefits is to:
- Use generic prescribed medication wherever possible.
- Request that claims are paid at the scheme's rate and to claim within specified sub-limits.
- Fund non-critical items from your pocket to retain funds for essential expenses.
Use generic prescribed medication wherever possible.
Request that claims are paid at the scheme's rate and to claim within specified sub-limits.
Fund non-critical items from your pocket to retain funds for essential expenses.
There are so many factors to take into consideration that it is best to contact your scheme or accredited broker for a medical needs analysis.
For further information
Contact: Melanie Kirsten (021) 852 1183
Email: Melanie.kirsten@psgkcorporate.co.za
083 286 7110
Article first published on - http://www.fanews.co.za/article.asp?Healthcare;6,Medical_Schemes;1078,Struggling_to_decide_on_your_medical_aid_option_for_2012;10955
