Choosing A Suitable Medical Scheme Option

When looking for a suitable medical scheme most people concentrate on factors like

their current medical needs, the possibility of future healthcare needs and how much many they have available to spend on private healthcare. Most people focus solely on contributions. They purchase cover according to what they can afford and mistakenly think that the best cover will be the most expensive scheme option in their affordability range. This is not the case.

Using a medical aid broker to help you way up your options can help, but unfortunately brokers are biased towards schemes that they have relations with and will try to convince you to sign up with one of them instead of giving you impartial advice. Like they saying goes, "If you want something done right, do it yourself". Comparing monthly contributions is simple enough and can be easily done using a number of price comparison websites. However there are other variables that need to be compared before making a decision. These include:

Limits

Low and mid level scheme options typically have overall benefit limits and sub-limits. If the overall benefit is capped then it is essential that you check whether this limit applies to the main member and all dependents separately or if it applies to a combination of all members and dependents. Then check whether the benefits are sufficient to cover your entire family should you all be involved in a car accident. Sub-limits are also important. These typically come in the form of a limited number of GP visits per year or a limited number of eyeglasses per year.

Exclusions

Check if any conditions or procedures are excluded. Not having cover for treatments like transplants or chemotherapy could cost you or a loved one their life.

Networks

Some medical scheme options use medical services networks to bring down the cost of contributions. There are usually three types of network options. Unlimited private options mean that you can use any hospital or doctor. Limited network options entail only being able to use a list of hospitals and doctors that are approved by the scheme. By creating these networks schemes are able to control costs better. Some low-cost options involve the use of public hospitals in their networks.

Reference Price List

The Department of Health has a list of guideline tariffs known as the Reference Price List (RPL). Many medical schemes in South Africa use these rates to set their benefits. However, many doctors charge above the RPL rate meaning that you end up paying this extra cost yourself if you are not adequately covered. Typically benefit options will cover 100% RPL, 150% RPL, 200% RPL or 300% RPL. The RPL rate is a crucial factor to be taken into account when comparing schemes and benefit options. To make things even more confusing, some schemes have rates of their own that are loosely based on the RPL and refer to them as "Scheme Rates". Trying to compare an option with 100% RPL to an option with 100% Scheme Rates is futile.

Co-payments

Co-payments are used by schemes to reduce costs and prevent unnecessary doctor and hospital visits. It is kind of like the excess on your car insurance. You are required to pay a certain amount or percentage of costs before your medical aid cover kicks in. By including co-payments, schemes ensure that you use medical services only if you really need to.

If you find the option you are interested lacking as far as RPL rate and co-payments go, then you can take out separate gap cover insurance policies. Doing this might work out to be cheaper than going for a more expensive medical scheme option.

Once you have compared these variables, you should have a very good idea of whether the medical aid scheme and benefit option that you are interested in is the right one for your needs.

by: Stuart Broad

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