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Making your medical aid benefits last

18 March 2021 Bonitas Medical Fund

Around 9 million South Africans are members of medical aid schemes to ensure they have access to private healthcare. As each new year begins, members start with a clean slate, with new benefits and replenished savings. However, across the industry, members often complain that their benefits seem to ‘run out’ early on in the year.

If you manage your medical expenses correctly you can avoid out-of-pocket expenses and limit the possibility of running out of benefits.

Here are 8 tips from Lee Callakoppen, Principal Officer of Bonitas Medical Fund, on how to stretch your medical benefits to maximise your value.

1. Use DSPs or networks
Medical schemes negotiate preferential rates with providers – known as Dedicated Service Providers (DSPs) - who have partnered with them. This allows schemes to ensure that members get the best quality services at the most cost-effective rate so that benefits are optimised and the scheme at large is sustainable.

Using network doctors is an invaluable tool to helping make your medical aid last longer because it means you won’t be charged more than the negotiated amount. With over 6 000 GPs, Bonitas has the largest network in South Africa

2. Ask your pharmacist
Buy over-the-counter medicine to treat less serious ailments and always, where possible, use generic medicine which has the same active ingredient, strength and dosage as the original brands and are just as effective. Pharmacists are able to provide sound medical advice on problems such as rashes, colds or illnesses that are not severe, simply ask!

3. Managed Care benefits
Some schemes offer programmes to help you manage severe chronic conditions such as cancer, diabetes, HIV/AIDS and back and neck problems These programmes are usually covered from the risk portion of your medical contribution and are not funded from your savings account. They help you use your benefits to maximum advantage while ensuring you receive quality care by using specific providers.

Other benefits - such as maternity consultations, wellness benefits, preventative care and dentistry – are also paid from risk by some schemes. Again giving you more value for money and are in addition to your savings and day-to-day benefits.

Carefully read through what your plan offers and choose wisely to make sure you find the right plan to suit your specific healthcare needs.

4. Go virtual
Look out for telemedicine or virtual consultation options – which are cheaper. A doctor will engage with you in a virtual video consultation on any medical issue and advise you on the most clinically appropriate steps for further care.

5. Be aware of consulting after hours
In an emergency one has no choice but be aware that after hours consultations are expensive.

6. Know the facts
If you do need to be hospitalised and it’s not an emergency, ensure that the healthcare practitioner is on your medical aid’s DSP list. Talk to your doctor or specialist to find out all the facts in terms of what they will be charging and compare this to what your scheme will cover. If the difference is substantial, negotiate. Approach your doctor and ask if he/she is prepared to adjust their fee. Alternatively, you can also check if there are other healthcare providers on your scheme’s network that will charge you a better rate.

You can also avoid the unwelcome surprise of a co-payment or sub-limits by:
• Making sure you obtain pre-authorisation
• Making sure the medical practitioner uses the correct ICD-10 codes
• Getting a quote from the doctor, hospital and anaethetist and submit it to your medical aid to see which additional costs will apply (if any), what costs will be covered and how you can avoid these.

7. PMBs
If you suffer from a Prescribed Minimum Benefit (PMB) condition, understand what benefits are provided as part of PMB conditions and use the service of a DSP to ensure your claims are paid from risk rather than from your medical savings account.

8. Keep moving
One of the best ways to manage your health and the associated costs, is to live a healthy lifestyle and this includes getting enough exercise. Try different exercise routines and find one that works for you. Whether it is a regular short power walk, playing tennis or soccer, riding a bike or attending a yoga or pilates class, it will be beneficial to your mental and physical wellbeing.

‘Be informed’ says Callakoppen. ‘Your health is important, as are your finances, so take the time to research and understand the medical aid plan you’ve chosen. Even if you have not changed plans your benefits and savings differ year-on-year. Make sure you read the information sent to you, including the fine print to understand the Scheme Rules fully. If in doubt, phone the call centre, your broker or financial advisor. This will go a long way in helping you know your rights and making the most of your benefits.’

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Covid-19 may accelerate certain industry trends. What are we likely to see?

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