Category Healthcare
SUB CATEGORIES General  |  HIV |  Medical Schemes | 

Make sure your medical aid caters for your changing needs

08 October 2013 Peter Jordan, Fedhealth
Peter Jordan, Principal Officer of Fedhealth Medical Scheme.

Peter Jordan, Principal Officer of Fedhealth Medical Scheme.

As we enter the last quarter of 2013 and all the medical aid schemes start releasing their benefit increases for 2014, it's time to re-assess your medical aid and decide whether the benefit structure of your current scheme is adequate to cover your needs in 2014.

Peter Jordan, Principal Officer of Fedhealth Medical Scheme, says that every year each member should assess their current healthcare needs based on their age, family composition and health status and select an appropriate option which will cater for this level of need. "A member selecting an option based on affordability rather than healthcare needs should be fully aware of the risk of having to cover certain healthcare costs out of their own pockets.

Members on inappropriate options often blame the scheme for what they perceive to be inferior benefits rather than acknowledging that the scheme is only providing benefits that match their level of monthly contributions,"
comments Jordan.

Jordan cautions members against falling into the trap of selecting the cheapest option available without understanding the resultant loss in benefits. "Members should compare rates and benefits of different schemes and look at rate increases over the last couple of years. One must however remember that price should never be the only key determinant as service levels are, if not more, as important," he says. "It is important to look at service in terms of how claims are paid as well as the communication in place to allow members to keep on track of claims processing. A superior call centre as well as dedicated client liaison officers for companies to meet with clients and resolve member problems on site, are essential."

When analysing different scheme options Jordan says intermediaries can play a vital educational role in assisting members to not only make the correct choices but to manage their medical scheme expenses more effectively. "When discussing options with their medical aid expert, members should confirm the financial stability of the scheme they are considering including the credit rating and solvency. All schemes are required by law to maintain reserves of at least 25% of total contributions," says Jordan. "Global Credit Rating (GCR) is also a good indicator of any scheme's claim paying ability and ratings of AA and AA- are considered acceptable."

Understanding the level of cover you will receive is another important aspect to take into consideration. "Members need to check and understand the reimbursement rates when it comes to specialist rates." It is also important to check benefit limits on certain options to ensure appropriate cover, he adds.

Jordan urges members to ensure they understand what claims get paid from what benefits. "Members need to understand where money is drawn from, for example: does the scheme pay for certain out-of-hospital benefits from Risk or only savings?" he says. "They also need to ensure they make the most of their benefits. For example if members have a chronic condition they should be applying for chronic medicine authorisation, otherwise it will be paid for from their day-to-day benefit."

In addition Jordan advises members to ensure they understand the pre-exclusion clause and how it will impact on them. He explains that while medical schemes are not allowed to exclude any pre-existing conditions they can impose a waiting period of up to 12 months on all claims related to a specific condition. "Current legislation hinges on whether you have had more than a 90-day break in cover between your previous scheme and the scheme you are now applying to join. If you have a break in excess of 90 days, then the scheme can apply a three month general waiting period as well as up to 12 month pre-existing condition specific exclusion which can also be applied to PMB conditions. If there is less than a 90-day break in cover then full inter-changeability applies," says Jordan.

Should a member have more than two years continuous cover, Jordan says the scheme can only apply a three month general waiting period. However if the member has less than two years continuous cover, the scheme can apply up to 12 months pre-existing condition specific exclusions. "A late joiner penalty is applied to people who join a medical aid for the first time after the age of 35. It is another way of encouraging people to join the system earlier in life and to ensure medical sustainability based on the fact that the young and healthy subsidise the elderly," concludes Jordan.


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