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Know your medical aid benefits and avoid self payment gaps

20 May 2011 Fedhealth
Katy Caldis CEO of Fedhealth

Katy Caldis CEO of Fedhealth

With continuous price increases, consumers are still stretched to the limit and expenditure on a medical scheme is still a big expense for many families.

Katy Caldis CEO of Fedhealth, cautions members to manage day-to-day medical costs wisely in order to avoid self payment gaps.

Caldis says that in order to ensure financial stability of a scheme, medical schemes need to ensure that cover is provided for financially crippling illnesses and accidents that some members sadly experience, and that most medical aids do not provide unlimited cover for out-of-hospital benefits.

Most medical aid contributions cover members for major medical expenses, for example, in-hospital treatment as well as treatment for various dread diseases like cancer and also chronic medication. This, she says, is the core business of any medical scheme which is based on the insurance principle that risk is spread amongst a large number of participants.

Caldis continues to say that the primary reason for most people belonging to a medical scheme is to be covered as comprehensively as possible in the case of serious illness and accidents where a hospital bill and appropriate treatment in a private facility could financially cripple a family were they to fund it themselves.

Caldis says that members generally have access to flexible day-to-day benefits made up of an Out-of-Hospital-Expenses Benefit (pooled risk

benefit) and a savings account. Over and above these day-to-day benefits, some medical schemes such as Fedhealth provide an unlimited number of consultations throughout the year to GPs within its network on chosen options. In addition certain out of hospital benefits e.g. MRI and CT scans or trauma care in an emergency room, are not paid from available day-to-day benefits, but paid from the risk benefit.

Should members experience an abnormally high year of claims on their out-of-hospital expenditure, they will be covered by the safety net benefit.

Caldis offers advice on how to stretch day-to-day rands:

* Maybe the doctor is not necessary this time round. Before heading off to your doctor or rushing off to the emergency room, consider if you can get appropriate advice elsewhere which may save you time and money. Some schemes like Fedhealth have a Personal Health Adviser benefit which is a telephone call away. This benefit is offered to all members through Europ Assistance and is available 24 hours a day on 0860 333 432. Questions about unfamiliar symptoms, medical and drug information, common home remedies for dealing with sick children, nutrition and diet or more sensitive questions relating to your health are answered in the strictest confidence by experienced nursing staff. You will be advised to see your doctor where necessary. This is definitely an alternate avenue worth exploring.

* Ask about fees. Before your consultation starts, ask your healthcare professional about his or her fee structure. In some cases, healthcare professionals will charge less if you pay them yourself after the consultation and then claim back from the scheme for a refund at a later stage. This means that the healthcare professional gets their money quicker and also avoids the administration around the process of claiming from your medical aid. Although you have to submit the claim yourself, you generally get your money back within two weeks.

* Generics are just as good. Ask your doctor or pharmacist about generic equivalents for over-the-counter and prescription medication. These medications are of the same quality and efficacy as the original patented medicine and are considerably less expensive.

* A frame is a frame is a frame. Although many schemes will pay for designer frames for your glasses, it will leave you with less day-to-day benefits for the rest of the year. Therefore carefully consider the implications when selecting a frame. Shop around for special deals regularly advertised at the larger optometry outlets. Some of these outlets may even do an eye test for free if you buy your glasses from them.

* Know your benefits. It is definitely worth getting to know your benefits.

Find out if any unique benefits like specialised radiology or CT scans can be paid from Risk rather than Savings even when performed out of hospital.

Authorisation needs to be obtained at the end of the benefits and not after each one, otherwise it will be deducted from your Savings. Fedhealth pays more from risk than any other scheme.

"Remember that your savings account is your money and how you spend it is up to you. So please make sure you spend it wisely. Schemes are working hard to find ways of maximising the improvement in health outcome for every rand received in order to ensure a sustainable and affordable medical scheme into the long run," she concludes.

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