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Scheme Benefits - How Medical Aid Scheme Benefits Work

Understanding How Your Medical Aid Scheme Benefits Work

Without the financial support of specialised insurers, there would be few South Africans in a position to afford the services of a private healthcare facility or a specialist. Instead, they would be forced to join the ever-lengthening queues or waiting lists that have now become the norm for those seeking state-funded treatment. Though superficially similar to the policies offered by short- and long-term insurance companies, the cover provided by a medical aid scheme is more about tangible benefits than sums assured.

When insuring a car, for example, the policyholder’s vehicle will be covered for repairs up to a maximum value, and the claimant is required to obtain multiple quotes before the insurer will nominate a service provider and authorise a repair. By contrast, when providing cover for healthcare, the insurer must provide a comprehensive list of the all various conditions, treatments, and care included under the terms of cover and the maximum amounts that may be claimed in each case. These terms, in fact, serve to define the various benefits available to the members of a medical aid scheme, and these tend to vary both between alternative schemes and the various products that each of them offers.

Generally, a given company will offer a range of five or six products, priced according to the extent of the cover provided. This will often amount to full payment for items and procedures for which the tariffs charged for the services received fall within the limits set by the insurer. Where they fail to do so or where payment of a fixed percentage of the total cost may apply to certain services under the agreed terms, the member will then be liable for any outstanding co-payment. 

While generally, such outstanding amounts are relatively small and affordable for most members, it underlines the need to examine any product offered by a medical aid scheme closely, so as to be sure what benefits are, or are not included, before committing to it. Fortunately, under the terms of the Medical Schemes Act (131 of 1998), all schemes must provide cover for certain prescribed minimum benefits (PMB). These include all costs relating to the diagnosis, treatment, and care of 25 chronic illnesses, such as diabetes, epilepsy, and thyrotoxicosis.

Other changes introduced under the act ensure that nobody with a pre-existing condition may be denied cover for private healthcare. Instead, they may be subject to a mandatory waiting period before any claims relating to that particular condition will be accepted. Clearly, anyone in this position should check closely for details of any such condition that may apply to his or her medical aid scheme benefits.

Given that so many South Africans are now seeking ways to cut costs, the temptation to select cover for private healthcare based on monthly premiums is understandable. However, unless one can be certain that a chosen product meets all of the needs of the main member and any dependents, this could prove to be a false economy.

Often, even the closest scrutiny fails to reveal possible shortfalls, and this is why so many South Africans are turning to KeyHealth. With its what-you-see-is-what-you-get brand of clarity, affordable and relevant products, and core benefits not available from other medical aid schemes, it is not too surprising.

Medical Schemes - Affordable Medical Aid Schemes

Affordable Medical Aid Schemes Have Never Been More in Demand

Healthcare, whether state-funded or private, is a sector constantly beset by inflation. Not only is there a continuing upward trend in the prices of basic requirements, such as medication, disposables, utilities, food, and laundry services, but steady advances in technology puts pressure on hospitals and clinics to acquire new and costly instrumentation, such as that now used for various types of medical imaging. To compensate, the tariffs they charge patients must also be increased. This, in turn, puts pressure on medical aid schemes to provide affordable yet adequate cover in the wake of these constantly increasing costs.

Once agreed, their premium rates remain applicable for a given year, after which they are free to submit an application to increase their rates to the industry’s regulatory body – the Council for Medical Schemes (CMS).  In determining premium increases, each scheme is compelled to consider the possible impact on its members. They rely on the principle of shared risk like insurance companies. It is, therefore, important to maintain a sufficient number of members as, only by doing so, can they ensure the contributions of the majority of non-claimants will be sufficient to cover the cost of claims raised by the minority. Only when their products are affordable can medical aid schemes hope to maintain and grow their membership figures. Over the years, many have failed to do so, and have either been assimilated by rival schemes or been forced to liquidate.

Clearly, to continue creating a successful balance between the premium price and the benefits available to a scheme’s members has required some careful thought. In general, to ensure they remain viable, schemes have responded to this tricky challenge in a variety of ways. The more obvious of these has been simply to curtail some of the benefits. For example, lowering the maximum amount a member can claim for certain contingencies or eliminating selected benefits, such as specialised dentistry can help maintain affordable premiums for medical aid schemes.

One option that has proved quite successful is the hospital plan. Aimed at the young and single with good general health, it provides cover only during periods of hospitalisation, and offers a hedge against contingencies, such as car accidents and emergency surgery, which could otherwise incur crippling costs

As mentioned, membership numbers are crucial, and this has driven some funds to find ways in which to boost those numbers. Incentives, such as discounted gym memberships, movie tickets, and loyalty points are just some of the options that have proved to be effective. It should be borne in mind, however, that while this helps medical aid schemes to remain affordable, these perks must be paid for. Invariably, the only way to do so is for such schemes to curtail some of their core benefits.

Undoubtedly, one of the most successful approaches to this dilemma is that adopted by KeyHealth. Rather than curtailing its members’ benefits, the company has focussed on reducing treatment costs. To do so, it has recruited a network of preferred service providers who, in exchange for captive business, agree to apply preferential rates when treating scheme members. This has not only seen KeyHealth ranked among the most affordable medical aid schemes, but has enabled it to offer some unique and valuable added benefits at no charge.

Medical Aid - How to Choose a Medical Aid

Some Useful Tips on How to Choose a Medical Aid

With more than ninety individual funds currently operating in South Africa, finding the one that might best suit your needs and those of your family can be something of a challenge. In practice, however, if it is actually necessary for you to know how to choose a medical aid in person, then you can probably eliminate almost three-quarters of these from your search. Known as closed or group schemes, their membership is limited to specific groups, such as employees of a specific company; people engaged in a particular type of occupation, such as mining or teaching; or those who are members of a professional body, such as Chartered Accountants.

In the case of employees, membership is often automatic, and might be a condition of service with the employer contributing to the monthly premiums. In the other instances, group membership is an attractive option, as it makes discounted premiums possible. For the self-employed or for those whose employer is not allied to a group scheme, there are still about twenty-five open schemes, and so, knowing how to choose a medical aid will definitely be important. In practice, making that selection is a process that can be more than a little confusing, and the fact that the applicable terms and conditions are frequently shrouded in legal jargon with which most prospective members are unlikely to be familiar does little to simplify the decision-making process.

Inevitably, given the current economic climate, the cost of premiums will need to feature in that process. Price, however, should not be the sole consideration. Knowing how to choose a medical aid that will serve the needs of the main member and any dependent members will require striking an acceptable balance between its cost and the specific core benefits available to members under its stated terms.

Another feature that can assist greatly with the selection process is the reputation of the companies that appear to offer suitable products. In most cases, funds offer a range of five or six products in order to ensure that there is one that is adequate and affordable for most of its potential members. Because they are not-for-profit companies, membership numbers are important, and some resort to incentives to boost them. In the end, however, paying your medical bills will be more important than cheap movie tickets. These non-core benefits must be paid for somehow, and this could mean the insurer will need to curtail some core member benefits.

One of the keys to knowing how to choose a medical aid lies in avoiding the temptation to forfeit necessary cover in exchange for unnecessary gimmicks. It also involves understanding exactly what core benefits you will be getting for your money. Once again, this is where the reputation of a fund is so important, and what better guideline regarding the performance of any company could there be than its longevity?

Helping to finance private healthcare for South Africans since 1968, KeyHealth, with almost fifty years’ experience, is among the nation’s oldest and most trusted open schemes. With a choice of affordable products, each with clearly defined core benefits, including some that are totally unique at no extra charge, the name, KeyHealth, is all you need to know about how to choose a medical aid.

Medical Aid Quotes - Looking for Medical Aid Quotes Online?

Have You Tried Looking for Medical Aid Quotes Online?

Securing financial assistance with the cost of private healthcare was once no more than an option at a time when the state-run health service was in its prime. Since then, however, a combination of spiralling demands on its services and insufficient funds to sustain them has seen the state facility reduced to a mere shadow of the impressive system that once served as the model for a number of other countries. While a steady move to the private sector has resulted, private healthcare is just as vulnerable to rising costs, and to ensure affordability and good value. Looking for medical aid quotes online before making any commitment has become a sensible option for the citizens of South Africa.

It is, nevertheless, just as important for prospective members of a fund to be quite certain what they will be getting in return for their money as it is to know just how much of their hard-earned cash they will be required to part with each month. Put simply, while choosing a product for which the premiums are affordable is important, so too is the amount of cover it undertakes to provide for the member and, where relevant, for his or her dependents. Just like when booking a hotel or an airline ticket, the web-based entrepreneurs have been quick to provide comparison sites designed to eliminate the pain of looking for medical aid quotes online, one at a time.

By visiting one of these sites and providing a few personal details and a little bit of medical history, it is normally possible for an application to return multiple quotes directly to the screen. While this makes comparing the monthly premiums fast and simple, do not forget to check that your chosen product fully meets your needs. The best way to do this when looking for medical aid quotes online is to select two or three that fall within your affordable price range, and then check out the relative benefits of each, thoroughly. Alternatively, it is hard to beat KeyHealth products on price or core benefits.

Medical Scheme - The Basics of a Medical Scheme

What Are the Basics of a South African Medical Scheme?

Regardless of whether a state health service is available and how effective it may be, the demand for private healthcare is increasing worldwide. Without the buffer of state-funding, private practitioners and clinics are obliged to levy substantial fees in order to fund their services if they are to continue operating. As a result, the majority of those patients who choose to make use of private healthcare require help to meet the cost. One of the basics of a medical scheme is a mandate to provide its members with necessary financial support to meet the expenses involved.

To understand how these schemes operate requires some insight into the principle of shared risk, which forms the basis upon which all forms of insurance are founded – a principle predicated on statistical probability. In this instance, the probability is that, of all those covered under a given scheme, the vast majority will have no occasion to submit a claim during the cover period or, at worst, may make only relatively minor ones. As long as this assumption holds true, there should always be a sufficient reserve of premium income to meet the larger claims made by the minority. Hence, the basics of a medical scheme include an obligation to maintain an acceptable solvency ratio, as well as a sound international credit rating. The latter serves to provide a lifeline in the event that a fund should experience an unusual volume of high and valid claims.

When purchasing any product, most consumers would consider it important to know exactly what they will be receiving in exchange for the purchase price. In this respect, private healthcare cover is no exception. In this case, the product consists of a package of defined benefits detailing just how much a member is entitled to claim in the various categories listed. Since these benefits form the basics of a medical scheme, fund managers are required to provide details of all terms and conditions that apply to their products and which might influence the amount a member is entitled to claim under various circumstances.

For example, one of the products commonly offered by these organisations is the hospital plan and, while it offers extensive and valuable benefits, these are only applicable in those occasions when the member is undergoing treatment in hospital. Therefore, under all other circumstances, he or she is responsible for meeting the full cost of GP visits, prescription medication, and any other treatments that may prove necessary during the remainder of the year.

One of the basics of a medical scheme that can sometimes come as a surprise to new members is that they will be subject to an initial waiting period before any claims will be accepted. Though three months is the norm, new members with a pre-existing condition may also be required to wait longer before they can claim payment for services relating to the specified condition. The explanation is simple enough. The initial waiting period enables a fund to build essential cash reserves necessary to maintain mandatory solvency ratios, while the constraints applied to pre-existing conditions discourage opportunistic memberships of limited duration, which could threaten the fund’s viability.

However, the most basic requirement of a medical scheme is that, like KeyHealth, it guarantees value for money.