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Medical Aid - How Do I Choose the Right Medical Aid?

How Do I Choose the Right Medical Aid?

This is a question that many South Africans have asked at some time or another, and while there are a number of factors to consider, there are a few simple guidelines, which if observed, should help to make the task a little easier. Given the sad state of the economy, as is the case with most of the purchases we make today, the cost of obtaining cover is almost certain to be one of the factors in the decision-making process. However, while it might sound trite, you cannot put a price on your health or that of a loved one.  So, when asking: “How do I choose the right medical aid?” an important component of the answer must be to avoid making a decision based solely on the price.

You may choose a pair of shoes because they are inexpensive, but you will only do so if they are a comfortable fit. Likewise, if your objective is to ensure that you, and the members of your family, will be able to receive all of the private healthcare they might require in the event of illness or injury, you should only settle for a product that is the best fit for your collective needs. In other words, even if you may have a limited budget, in answer to the question: “How do I choose the right medical aid?” the simplest advice is to be sure you choose the product that offers you the most bang for your buck.

Many of those in full-time, formal employment are unlikely to be faced with this choice. For them, membership of a nominated group or closed scheme will often be a mandatory condition of employment. In such cases, the monthly payments are invariably less of an obstacle, as group membership generally qualifies members for a discounted premium. In addition, a joint contribution from the employer will usually serve to reduce the premiums even further, while the balance paid by the employee qualifies for tax relief.

For the self-employed, or for those whose employers have no affiliation with a group scheme, the question: “How do I choose the right medical aid?” is one that is more relevant, and making the right decision will require making some comparisons. With more than 25 open schemes to investigate, each of which offers a number of different options, choosing the best one for you would once have been something of a marathon task. However, the digital age and the subsequent spread of internet access now offer a far quicker and simpler approach in the form of dedicated comparison sites.

How do you choose the right medical aid? Simply answer a few on-screen questions and a search engine retrieves all of those schemes that meet your stated requirements. The first step is to select those in which the monthly premiums are within your budget. Finally, you need to take a closer look both at the companies responsible for those schemes and the choice of products that each offers.

With 50-years’ experience, a track record for meeting claims on time, and affordable, no-frills products that focus on maximising core benefits, many of which are totally unique, KeyHealth is increasingly the answer for those who ask: “How do I choose the right medical aid?” 

Medical Schemes - Affordable Medical Schemes in South Africa

Affordable Medical Schemes are Becoming Increasingly Important in South Africa

With the economy still in the doldrums after the 2008 recession, the state health service is among the nation’s facilities worst hit by the crippling shortage of government funding. With many hospitals reduced to providing only primary care, it is a situation that seems destined to continue in the absence of a realistic contributory system to offset rising costs. The impact of the latter has also affected private healthcare, prompting a growing need for more affordable medical schemes in South Africa that will make it possible for more of its citizens to benefit from access to private medicine.

Under the terms set by the Council for Medical Schemes, the industry’s regulatory body, a fund is entitled to increase its premiums annually, subject to the body’s ruling on what represents a valid increase in the prevailing circumstances. Though private hospitals, clinics, specialists, and general practitioners all have a duty of care, they are also obliged to remain profitable if they are to continue meeting that obligation. When inflation forces the cost of medicines, disposables, capital equipment, and incomes higher, it means that special measures are required in order to ensure affordable medical schemes in South Africa.

If you take a close look at the items you buy regularly from your local supermarket, you will notice that the prices of some items have escalated dramatically, whilst in other cases, the increases may be more modest. Take an even closer look, and you will often find that the explanation is that, in exchange for keeping the increase to a minimum, you are now getting slightly less for slightly more. Similarly, one of the means by which some funds choose to keep their premium increases down is set lower limits on some of their benefits. The decision may be a financially sound one, but from the member’s viewpoint, it simply means increased liability for service providers’ fees in exchange for more affordable premiums from such medical aid schemes in South Africa.

Creating a balance that is acceptable both to the trustees of a fund and to its members can be a challenge, to say the least. If premiums are perceived as too high, prospective members will naturally tend to look elsewhere. Without sufficient members, however, the funds, which are all not-for-profit companies, would be unable to maintain sufficient cash reserves to guarantee meeting their claims. With membership numbers so crucial to a fund’s solvency, many resort to offering new members incentives, such as free gym membership or movie tickets and loyalty points that can be redeemed for goods. In practice, these non-core benefits must be paid for at some point while the result may appear to be more affordable medical schemes in South Africa, the real price is less cover.

In order to succeed in its efforts to attract new members, it should not be necessary to entice them with such incentives, providing the core benefits are seen to be of sufficient value, appropriate to the needs of both the main member and his or her dependents, and within the family budget. KeyHealth has achieved these criteria by combining a network of preferred service providers, with some unique and invaluable core benefits to become one of the most affordable medical schemes in South Africa.

Medical Aid - Claiming from Your Medical Aid

Claiming from Your Medical Aid Should Not Be a Hassle

The vast majority of South Africans who enjoy private healthcare would be totally unable to meet the cost of private treatment if they did not receive some form of financial support for this purpose. Young and single citizens with good general health, may be concerned only with meeting the cost of an unexpected emergency, and might choose to purchase cover that applies only when hospitalised. However, those who are older and have families to support will generally want more comprehensive cover. However, regardless of how much or how little cover you may choose, in an ideal world, claiming from your medical aid should never be a problem.

Sadly, the real world is far from ideal, so this is not always the case. Much of the time, it is a member’s failure to understand the terms and conditions concealed in the small print that is the root of the problems commonly experienced by claimants. For example, because service providers are at liberty to set their own fees within certain limits, the amount agreed by a fund as the limit for a given procedure may fall short of the fee levied by the service provider. In such cases, the shortfall between the actual cost and the maximum sum agreed will be for the account of the member. Known as co-payments, these should not cause problems, providing you are aware of this possibility when claiming from your medical aid.

Other confusions arise as a result of limits. There may, for example, be an annual limit on the total amount of cover available for routine dentistry. In other cases, such as when cover for a new main or dependent member with a pre-existing condition is withheld during an initial waiting period. Once again, providing such conditions are clearly stated and displayed prominently in a member’s documentation, this should not result in any unpleasant surprises. One thing everyone needs to be aware of is that, whether you are a new main or new dependent member, there will be no point in claiming prescribed minimum benefits from your medical aid until the legally-permitted 90-day waiting period has expired.

To a degree, just how the remuneration process operates is also up to the requirements of the service provider. Many require an up-front payment from their patients who must then apply to the appropriate fund for reimbursement. In other instances, however, the member may have no need to become involved in the claims process at all. Some service providers choose to undertake this process on behalf of their patients as and when it becomes necessary. Where this is the case, you remain responsible for any co-payment that might apply whilst relieved of all responsibility for claiming a refund from your medical aid.

While the role played in South Africa by these non-profit organisations is invaluable, they are still businesses that require members to continue operating, often promoting membership with incentives that must be paid for, either by increased premiums or reduced cover. At KeyHealth, the policies of total transparency, simple understandable terms, and focussing on core benefits ensure exceptional value for money. Furthermore, with the option of uploading, emailing, and submission via a mobile app or the post, claiming from your medical aid could not be easier. 

Medical Aid - Understanding the South African Medical Aid Scheme

Understanding the South African Medical Aid Scheme

Some will recall the days when our state healthcare system was seen as a model for other countries. Since then, however, a combination of factors, including rising demands and underfunding have led to its steady decline, prompting a mass migration of patients to the private sector. As is the case elsewhere, without some form of assistance, few patients could afford private healthcare. For the South African, that assistance takes the form of a medical aid scheme.

Although they operate on the same basic principle as the insurance company that provides cover for life or damage to fixed property and motor vehicles, they differ in terms of the benefits they provide. In order to accumulate the cash reserves with which to meet claims, both depend upon shared risk. The principle assumes that, statistically, the majority of those covered will make no claims or only minor claims in a 12-month period of cover, and that their premium contributions will suffice to pay the large claims of the minority.

However, while insurers pay a pre-agreed fixed sum, setting the premiums accordingly, a South African medical aid scheme is obliged to meet the full cost of a treatment, or at least the bulk of it, depending upon the product option chosen by its members.

Significantly, full payment of certain private healthcare costs is now mandatory, following the introduction of prescribed minimum benefits (PMBs) by the Council for Medical Schemes (CMS). In addition to emergency treatments, the mandate requires schemes to meet all costs relating to the diagnosis, treatment, and care of 25 listed chronic illnesses. While many insurance companies now offer some form of medical insurance, their regulatory body does not require them to cover PMBs or to meet the full cost of any treatment.

Generally, insurance companies offer a hospital cash plan that pays a fixed sum for each day the policyholder is hospitalised. While KeyHealth, for example, also offers a hospital plan, unlike most South African medical aid schemes, and provides full cover for in-patients, it also includes some year-round benefits.

Medical Scheme - What Is A Medical Scheme, and How Does It Work?

What Is A Medical Scheme, and How Does It Work?

For those who are just starting out on their chosen career, or have found themselves without parental support for the first time in their lives, it might be reasonable to wonder what a medical scheme is, how it works, and whether or not they may need one. On the other hand, those who are a little older, are well-established in their careers, and may even be married with a couple of children, even though they may not understand everything about its operation, are certain to be well aware that membership is not just some nice-to-have option, but a dire necessity given the sky-high cost of private healthcare, and the parallel decline of the state-funded health service.

So, what exactly is a medical scheme? In South Africa, it is a facility offered by around 90 non-profit companies that essentially acts as a form of insurance policy that pays out when the policyholder requires health-related consultation, treatment, or hospitalisation from a private healthcare provider. Generally, the sum paid by the insurer will cover most, if not all of the costs arising from a claim. In practice, however, their section 21 status means this distinguishes the permitted practices of these schemes from those of a commercial insurance company, although the principle upon which the success of both types of operation is dependent is that of shared risk.

What is essential to both a medical scheme and an insurance company is that the majority of its contributors, whether members or policyholders, will either lodge no claims at all or claim only minor amounts over the course of any given 12-month period. In turn, the accumulated income from premiums must be sufficient to ensure meeting the more substantial claims of the minority. However, while the commercial insurers must also produce profits for their shareholders, they remain aware of their total potential liability at all times, while their not-for-profit equivalents and their boards of trustees must rely more on good governance and controlling operational costs.

Another significant difference between what is required of a medical scheme and a commercial insurer is that the former is obliged, by law, to provide cover for certain prescribed minimum benefits as determined by the CMS (Council for Medical Schemes), their regulatory body since 1998. While commercial insurers are also entitled to offer a curtailed form of medical insurance, they are bound by no such regulation, and the sums paid to claimants are based solely on the premiums charged, and, in practice, will actually contribute very little to the overall cost of the policyholder’s treatment.

The cost of private healthcare continues to rise each year. Improved medications are invariably more expensive than their predecessor, while technological advances, such as medical imaging, exert pressure on hospitals and clinics to update their facilities. In the wake of these increased costs, what is crucial for a medical scheme is to find ways in which to avoid premium increases or, at least, to keep them to a minimum.  

Some will attempt to do so by restricting their benefits, while others may seek more innovative solutions, such as forming a network of service providers prepared to offer preferred tariffs in exchange for a captive market. KeyHealth combines a network of expert providers, exceptional benefits, and competitive premiums.