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Medical Schemes: Balancing your client’s premiums and benefits

01 November 2012 FAnews

Private healthcare is a ‘big numbers’ game. The Council for Medical Schemes reveals you’re your clients contributed roughly R107.4 billion in gross premiums towards their medical schemes and medical savings accounts last year. Average medical schemes contributions topped R1063.90 per family member per month!

November and December are busy months for the private healthcare sector. Medical schemes are hard at work publishing their tariff increases and changes to the benefits offered on various options, while your clients must decide which option best meets their premium and benefit needs.

Private medical schemes members tend to stick with the benefit option they know. Discovery Health statistics going back three years confirm that more than 93% of its members elect to stay on their existing benefit options. Only half of the 7% who change options choose to downgrade.

How can you assist your clients in making the right medical schemes choice? To begin with you can page through our comprehensive summary of 2013 premium increases that shows how much each open medical scheme and benefit option will cost your client. We also provide a summary of some of the major benefit changes you should be on the lookout for.

Benefits worth mentioning for 2013

Momentum Health
• Members will be able to earn up to R5400 in HealthReturns and also earn up to four extra GP visits (paid by Momentum) based on maintaining a high level of activity. These GP visits can be used by the member and/or any of his dependants over the next 12-month period.
• Members will be able to change their HealthSaver contributions online and reimbursements will be made daily.
• Maternity: One extra antenatal visit added on Ingwe and Access options, benefits for doulas (as alternative to a midwife) added to all options.
• Chronic: Wider, more up-to-date range of medicines to be included in formularies, managed by industry expert.

Genesis
• Diagnostic scope benefits increased by 25% to R2 000 per scope (Private, Private Plus & Private Comprehensive).
• New benefit for crowns / provisional crowns introduced (all benefit options).
• MRI and CT scans: New out-of-hospital benefit up to R5 000 introduced (Private, Private Plus & Private Comprehensive).
• Rehab benefits following a stroke increased by 6.7% to R80 000 (Private, Private Plus & Private Comprehensive).
• Benefit for immunosuppressant medication increased by 5% to R84 000 (Private, Private Plus & Private Comprehensive).

Bestmed
• An orthopaedic and medical appliances benefit added for in-hospital services.
• Biometric Screenings added to preventative care benefits.
• Day-to-Day overall limits adjusted on Pace1, 2 and 4 to accommodate optometry benefits.
• In-hospital co-payments removed from Pace4.
• Sub-limits on hearing aids increased by more than 7% and limits are now available annually instead of every 48 months on Pace 2, 3 and 4.
• Structural changes made to Pace 3: Out-of-Hospital benefits payable from annual MSA first. Once annual savings are depleted scheme benefits will be paid up to the mentioned limits.
• Biometric Screenings for all beneficiaries older than 10 years on an annual basis at Dis-Chem pharmacies and Clicks clinics only, to include blood pressure measurement, Body Mass Index and rapid tests for glucose and cholesterol.
• PPN Optical Benefit added to Beat 3, Pace 1, 2, 3 and 4 at cost of PPN Provider. This is a Scheme benefit (not paid from savings) and includes an eye test and spectacles. Qualify for either one pair of Clear Aquity single vision lenses or one pair of Clear Aquity bifocal lenses or one pair of Clear Aquity multifocal lenses. Limit to specified amounts as listed per option.

Selfmed
• Benefits limits increased on all options with inflation.
• Elective Joint Replacements on the Elite option have a co-payment of R9 500.

Profmed Medical Scheme
• Annual overall day-to-day limit increased by 6% on ProPinnacle, ProSecure Plus and ProSecure options.
• Tarrifs increased on all options by 6%.
• Hearing aid limit increased on all options.
• Intraocular lenses increased.
• Functional Orthognathics surgery limit increased in ProPinnical option.
• HPV Vaccine covered on all options.
• No co-payment on admission to hospital.
• Oral contraceptives covered on all options.

Discovery Health
• Upfront discount of 20% on all frames and lenses at an extensive new optometry network for members of DHMS and all other schemes managed by Discovery Health.
• Members registered on the Chronic Illness Benefit for hypertension, hyperlipidaemia, diabetes or asthma will qualify for up to 25% cash back on a wide range of items purchased from Dis-Chem stores countrywide.
• A new plan at the entry point of R450: KeyCare Access Plan, for the lower income earners and people who are currently uninsured.
• A range of online support tools and technologies, and smartphone applications to help members to keep track of benefits, authorise hospital admissions, order medicine, find healthcare professionals, manage chronic conditions and keep track of claims online. Members can access their personal health records, order door-to-door medicine delivery, check medicine prices and alternatives, track claims and medical spend, request documents, view information on hospital procedures, translate travel cover into one of five languages and watch educational videos.
• Members on Executive or Classic Health Plans can receive up to 25% cash back on their HealthyFood purchases at Woolworths.
• New partners include Builders Warehouse and Builders Express, Incredible Connection and Sunglass Hut.

Liberty Medical Scheme
• Cover for Radio-Isotopes from risk benefits on all options (currently paid from savings).
• Risk benefit for two GP consultations per family per year, including fees charged for submitting relevant clinical information to allow more effective case management, if the member uses a Liberty Health Network GP on the Platinum Complete, Platinum Saver, Titan, Titan SELECT, Gold Saver and Gold Saver SELECT options.
• Increased co-payments for scopes and joint replacements by 25% on the Platinum Saver and Platinum Focus options.
• Introduction of a Liberty Medical Scheme GP Network.
• An inflationary increase of 7.0% has been applied to all benefit limits and self-payment gaps.
• Provide cover for oral contraceptives from savings accounts (currently an exclusion) on all options with savings accounts.
•Provide a risk benefit for 2 GP consultations per family per year, including fees charged for submitting relevant clinical information to allow more effective case management, if the member uses a Liberty Health Network GP on the Platinum Complete, Platinum Saver,
Titan, Titan SELECT, Gold Saver and Gold Saver SELECT options.

Medihelp Medical Scheme
• New network option on Dimension Prime range of benefit options. Members who choose one of the Dimension Prime network options will see a weighted average increase of between 0% and 2.4%.
• Maximum benefit limit amounts have increased by approximately 6% on average on all options.
• Benefits for child birth at home included on all options.
• Hip, knee and shoulder replacements for non-PMB cases are now included on the Dimension range.
• Removal of impacted teeth during hospitalisation added to the Dimension Prime range.
• Consultations at contracted specialists to be covered at 130% of the scheme tariff on Dimension Elite and Medihelp Plus.
• The co-payment on adenoidectomy and/or tonsillectomy has been removed from the Dimension range.
• The Scheme has boosted its preventative care benefits on its Dimension range and Medihelp Plus option with the following enhancements: Benefits for circumcision in doctors’ rooms, benefits for neurostimulators, bone mineral density tests for females 50 years and older and standard immunisation for children younger than seven years.

Fedhealth
• Hospital plans include a 33% expansion of hospital network coverage.
• Innovative screening benefits on both hospital plans and one GP visit per beneficiary per year to members on hospital plans.
• Significant self-payment gap decreases and screening benefits on comprehensive options.
• Unlimited GP visits paid from Risk and never Savings on comprehensive options.
• Trauma treatment paid from Major Medical Benefit.
• Specialist radiology paid from Major Medical Benefit.
• Child dependant status up to 27 years for children studying or financially dependant on the principal member.
• 30 Day post hospitalisation benefit for certain treatments after discharge from hospital.

TopMed
• Introduction of a new option – TopMed SavingsPlus* which is the hybrid option. Members contribute to a monthly saving, but once depleted the scheme continues to fund day-to-day benefits from a Routine Benefit, subject to an overall limit. (*Subject to approval from the CMS).
• Benefit Limits increased by 7%.
• Introduction of a new option - TopMed SavingsPlus* which is the hybrid option. Members contribute to a monthly savings – but once depleted the scheme continues to fund day-to-day benefits from a Routine Benefit, subject to an overall limit. (*Subject to approval from the CMS).
• Dentistry Benefits on Traditional, Savings and Professional Options paid from risk.
• In-hospital specialists paid at 150% of TT on the Traditional, Professional and Hospital Options.
• Extended Major Medical Benefits offered on all options (except the Network Option).
• Wellness /Preventative Care Benefit offered on the Savings, Professional, SavingsPlus, and Hospital Options.

Quick Polls

QUESTION

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ANSWER

Very confident, insurers prioritise fair treatment
Somewhat confident, but improvements are needed
Not confident, there are significant issues with fair treatment
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