Medical costs keep rising, usually above the inflation rate, so it’s essential you stay in contact with your medical aid, medical practitioners and brokers to ensure you get the best bang for your buck.
Most medical aids have launched their benefits and premium contributions for 2017 and, as in the past, the increases are in the double digits and outstrip inflation.
Dr Bobby Ramasia, Principal Officer of Bonitas Medical Fund, says now, more than ever, is the time to box smart to maximise your medical value from your medical scheme benefits.
Understand your benefits
Read the information sent to you by the scheme/broker. Attend any information sessions at your workplace to get a better understanding, he says.
Getting the best out of your hospital cover:
- If your scheme has appointed a Designated Service Provider (DSP) network for hospitals, you will usually pay a lower monthly contribution in exchange for using a hospital or doctor from this network for planned procedures.The penalty for using providers not contracted with the scheme is usually the payment of shortfalls or co-payments. For planned procedures, check with your scheme if you will obtain better cover by using contracted providers or having the procedure performed in the doctor’s rooms or day clinic.
- If you are going to be admitted to hospital for a planned procedure, always check at authorisation stage, if there are any co-payments or sub-limits that will apply. An example here is for joint replacements, where most schemes have specified sub-limits if you do not use their DSP.
In terms of the Medical Schemes Act, there are 26 common chronic illnesses all schemes are required to cover for medication and treatment. But schemes can apply measures to contain costs.
- Almost all options on all medical schemes apply a medicine formulary, a list of drugs the scheme will cover in If you use medication not on the formulary, you will be liable for the difference in cost. So discuss medication with your doctor to see if this is appropriate.
- The schemes can also specify that you obtain your medication from DSP pharmacies. If there are none close to you, most schemes also designate a courier pharmacy to deliver the medication.
Many medical schemes also cover additional chronic illnesses – usually from the more expensive options – if your particular condition is not covered, it is worth further investigation. This cover is at the scheme’s discretion and conditions covered vary.
Know your rights
In terms of a high court ruling, medical schemes are obliged to meet the cost of in-hospital Prescribed Minimum Benefit procedures at cost, in full. Make sure you know what “in full” means. If you have been admitted to hospital, check with your doctor to avoid any shortfalls – and ask for your broker/consultant’s assistance.
A medical aid co-payment is a fee the member is liable for when using certain medical services. The medical aid would not cover 100% of the costs and the member would have to pay for a certain percentage before the medical aid pays. These co-payments usually apply to specialist or elective medical procedures. This will differ from one medical aid scheme to another. It is one of the reasons you should always do thorough research before deciding which medical aid scheme is the best option for you.
Talk to providers
Talk to your doctor/specialist before before a planned procedure. Check what they will be charging and what your scheme will cover. Don’t be afraid to approach your doctor to see if they are prepared to adjust their fee.
As published on MONEYWEB. Download the original PDF article here.