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What to consider when selecting a medical aid option for 2013

Amid increasing costs of living and industry discussions around the readiness of the South African healthcare industry for the impending implementation of NHI, many people will undoubtedly be reassessing their medical schemes and considering switching to an alternative plan in 2013.
Graham Anderson, Principal Officer at Profmed, the medical scheme catering exclusively to graduate professionals says it is critical for people to regularly re-assess the medical plan that they are on to ensure that it is still appropriate to their profile.

Changing needs/options

"People's needs change all the time. Furthermore, medical schemes usually alter their design and benefits on a yearly basis. Therefore, a review of one's situation should ideally take place on an annual basis or whenever a member goes through a life-changing event," he says.

For example, Anderson says a member who has recently acquired a degree could qualify for specific medical plans that offer more specialised services and additional benefits for professionals.

"Life stage also plays an important role when considering a medical plan. A single young professional or a young couple are unlikely to require comprehensive cover but rather a good hospital plan, preferably with no limits on hospitalisation and no co-payments or deposits on admission to hospital. Alternatively, a family with children would probably require a more comprehensive benefit, which includes out-of-hospital benefits. Once again, it is important to ensure that the hospital benefits and benefits for the major dread diseases are comprehensively covered," says Anderson.

Anderson explains that switching to a cheaper plan or a hospital plan could have some significant financial benefits - but only if the member is able to carry the cost of daily medical expenses.

Tiered contributions

The costs of different plans depend on both the level of benefits offered as well as the health of the average member on the plan. Generally, less healthy members tend to belong to plans offering more benefits - which often make these plans more expensive.

"By switching to a plan with lower benefits members should be grouped with healthier members, and therefore pay lower contributions. The savings made through lower contributions could be used for GP visits and other expenses out of pocket as they are needed," he says.

However, he warns that this approach requires members to understand the benefit structures of the different plans. "For example, the cover for oncology will often be lower or only available at specific providers on a lower cost option," he says.

Know your PMBs

Anderson also urges members to make sure they know their rights with regards to the Prescribed Minimum Benefits (PMB's), as this will also aid in the understanding of the best plan to choose.

"Essentially, there are certain conditions that a medical scheme is obligated to cover, irrespective of the plan you are on. This means that even if a member is on a hospital plan, he or she must be covered for PMB's, including where incurred out of hospital," he says.

Another important consideration is that some medical schemes make use of Designated Service Providers (DSP's) which members will be obligated to use for treatment of PMB conditions to avoid making a co-payment. In the above example, the hypertensive member may be required to use a specified pharmacy and GP. Anderson says members must make sure that they are happy with the DSP's available before they commit to a plan for 2013.

He cautions, however, that before choosing an alternative plan, members should be in full knowledge of their current health situation, realistically assess the risks they will bear and how these have been impacted by the change - and make provisions accordingly.