Category Healthcare
SUB CATEGORIES General  |  HIV |  Medical Schemes | 

Knowledge is power when choosing a benefit option

22 February 2019 Health Squared Medical Scheme

Go-to guide for medical scheme members

Confused about whether your chronic health condition is automatically covered as a Prescribed Minimum Benefit (PMB)? Do you know the difference between a traditional medical scheme option and a new generation option? Being a medical scheme member comes with many advantages, however there are important details one should understand when choosing healthcare cover.

“People who are joining a medical scheme for the first time and members who are not certain quite what their chosen benefit option entitles them to are at risk of either not making full use of their benefits or, worse still, discovering that they do not have adequate cover for their healthcare needs when they need it most,” says Bianca Viljoen, spokesperson for Health Squared Medical Scheme.

“Knowledge is power when it comes to medical scheme membership, and we therefore try to make information about our scheme as accessible as possible. A fundamental aspect in understanding how medical schemes work is that, by law, schemes must operate as not-for-profit entities and the money derived from membership contributions goes into a pool of funds that are used to cover the healthcare expenses claimed for.

Medical schemes are, furthermore, legally required to act in the best interests of their members and provide comprehensive cover for some 270 of the most common and serious medical conditions through prescribed minimum benefits (PMBs).

“For people living with chronic health conditions, an important factor in deciding on a particular benefit option is whether this condition will be covered. The PMBs include 25 chronic conditions, which medical schemes are obliged to cover irrespective of the member’s chosen benefit option, however on all Health Squared benefit options, our members have cover for 28 chronic conditions. ”

All medical scheme members should make every effort to find out as much as possible about their chosen benefit option and should ask the scheme for more information when they are unsure of anything. Members are encouraged to consult a healthcare broker annually to discuss their changing healthcare needs and also to pay special attention to communications from their scheme, which contain valuable information for members.
When selecting a benefit option, Viljoen recommends aligning healthcare cover to the common healthcare needs associated with your age group. “As people age, their healthcare needs tend to grow, and it is worthwhile to consider increasing – or at the very least maintaining – your level of healthcare cover as you get older.”

It is also essential to read the literature on your scheme’s benefit options, keeping in mind the benefits that you will not need. “Some options may be designed with a particular emphasis on maternity benefits, for example, but if you are a man with no dependents or a woman past childbearing age it is highly unlikely that you will take advantage of such benefits.”

She explains that there is a distinction between a traditional benefit option and a new generation option. “On a traditional option, the member has access to a set list of benefits over a one-year period and these are funded out of the risk pool of the medical scheme. Traditional options tend to offer good ‘rand value’ on out-of-hospital benefits however members’ access to benefits is more structured than is the case with new generation plans.

“On new generation options, up to 25% of the members’ premiums can be set aside and put into savings accounts in addition to set annual benefit limits.”

The savings portion of new generation options can be used to fund day-to-day healthcare expenditure such as visits to general practitioners, specialists and obtaining over-the-counter medication. This portion of the member’s funds cannot be used for cross-subsidisation of other members’ claims, and any leftover savings can be accumulated from year to year.
“It is important to be aware that by law co-payments cannot be funded from the medical savings account,” Viljoen says.

“Members should also remember that traditional options do not allow for a roll-over of benefits to accumulate year-on-year, so not making use of benefits now does not mean you will have double the benefits next year,” she concludes.



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