11 Pro Tips for Choosing the best Medical Aid plans in South Africa

11 Pro Tips for Choosing the best Medical Aid plans in South Africa

– Tanya Motlafe (Head of Cornerstone Healthcare Consulting Services)

Find the perfect medical aid plan for your family with our step-by-step guide. Match your needs and budget with the right choice. An important part of life planning for you and your family is making sure you’re spending wisely on medical expenses.

Here, you will learn about various medical aid plan types, their advantages and disadvantages, and how to evaluate your options to find the best fit for you. By the end of it, you will be able to make an informed choice about your medical aid coverage.

There are at least 18 open medical aid schemes in the country. Every year, medical scheme members have to renew their memberships, giving them an opportunity to re-evaluate their benefit options as their needs have changed.

But with so many benefit options across various medical schemes, the choices are vast and may be overwhelming. One of the best ways to ensure that you get the best medical cover for you and your family is to appoint a qualified and registered healthcare broker.

IN THIS ARTICLE 

  • Assess Your Current and Future Healthcare Needs
  • Understand the Type of Cover you Need
  • Never Exceed More Than 10% of Your Monthly Income
  • Look For Great Value Instead of Low Premiums
  • Do Your Due Diligence on Each Scheme Before Committing
  • Consider Your Age and Demographic in Your Decision
  • Look Into Exclusions, Waiting Periods and Late Joiner Penalties
  • Consider Gap Cover Instead of Upgrading
  • Research Managed Care Plans If You Have A Chronic Illness or Special Needs
  • Consider the Advancement of Technology for Convenience
  • Consult a Healthcare Expert or Consultant

1. Assess Your Current and Future Healthcare Needs

Do you know what you need to be covered for? One of the first things a medical aid broker will consider when advising you on choosing a plan is your immediate medical needs and what you might need in the years to come. Do you have a pre-existing condition? What are the needs of your beneficiaries?

Make sure that the plan you choose caters to your chronic needs. Furthermore, the level of cover for chronic conditions will vary greatly between different benefit options. Always, hiring a qualified and experienced healthcare broker is the best way to make sure you don’t get any nasty surprises or fall through any cracks. When thinking about your current and future medical needs, consider the following factors:

  • Pre-conditions – Some medical aid schemes make you wait a few months while paying monthly premiums before covering you for any illness treatment or medical need you developed before you joined the scheme.
  • Chronic illness – Some medical aid schemes are better suited than others for people looking for coverage for their long-term illnesses. If you will need constant GP and specialist visits, chronic medication and certain in-hospital services for chronic patients, this will factor heavily in your decision.
  • Dentistry or Optometry – Dentist and optometry services are generally expensive when acquired in cash and you might want to find a medical aid scheme that can cover these. If you have children or elderly beneficiaries you may need this service far more often than a single member.

2. Understand the Type of Cover you Need

Now that you have assessed your needs and those of your dependents, you will have a better idea of the kind of coverage you will need, and you can now begin weighing your options in the different medical aid plans against what you’re looking for. There are generally three types of coverage offered by medical aid schemes.

  • Hospital Plan – A hospital plan normally excludes most of the out-of-hospital benefits of a medical aid scheme and covers both planned and emergency hospital care and a few tertiary hospital care services. It is generally the most affordable medical aid coverage. But be sure what you’re getting into before you choose this option. A hospital plan only covers treatment and medical costs that arise while the insured is admitted to the hospital.
  • General Cover includes day-to-day hospital cover with a restricted network provider. Medical aid normally includes hospital expenses as well as other private medical needs including specialist consultations, GP visits, and further tests or procedures.
  • Comprehensive cover provides extensive cover compared to general cover. It may also include certain specialist services and elective medical procedures in its coverage. While the general cover may only provide certain in-hospital and out-of-hospital services, including GP visits, a comprehensive plan often provides for all of these needs.

3. Never Exceed More Than 10% of Your Monthly Income

No medical aid premium should cost you more than 10% of your monthly income as an individual or household. If it does, you can’t afford it. Even when you find a product within that price range, you have to ask yourself how long you can afford to spend that amount. You need not aim to spend exactly 10% of your income, and with the right guidance, you may even find a product that costs less than that.

Monthly medical aid premiums can be pricey, and it’s important to be realistic about long-term affordability when choosing benefit options. The higher-end, more comprehensive plans can easily set you back more than R4,000 per month.

If your medical aid contribution is too high, you will most likely end up canceling your medical aid due to affordability. This will have a negative effect if you ever decide to join a medical aid again in the future, because a late-joiner penalty fee may be imposed on your membership depending on your age due to a break in coverage for a certain period.

4. Look For Great Value Instead of Low Premiums

Low premiums do not guarantee the best value for your money. You may even end up paying more than you expected when something happens and you have to claim from your medical aid.

Most medical aid schemes experience price inflation at higher rates than standard inflation (5.7%). The Council for Medical Schemes (CMS) has recommended that medical aid contributions for 2023 stay at or below inflation. If premiums look too cheap, read the fine print. There may be high excess fees and other hidden costs.  Lookout for low sub-limits, high co-payments, and restricted access to specialists. Make sure you understand exactly what benefits are offered, what is excluded, and whether these meet your and your family’s medical needs

5. Do Your Due Diligence on Each Scheme Before Committing

Now it’s time to figure out which of your options is more medical aid cover and is the most credible and relevant to your needs.

For many of us, out-of-hospital needs like optometry, dentistry, physiotherapy, and psychiatry are just as important, if not more important, than in-hospital benefits. If you use out-of-hospital benefits, you’ll most likely need a medical aid benefit option that has a Medical Savings Account (“MSA”) or a traditional plan. Many benefit options don’t have a medical savings account, and you won’t have coverage for day-to-day benefits, so make sure you choose the right plan for your needs.

Find out if the medical scheme you’re considering is financially viable. It’s important to know how safe your monthly contributions are. You can easily assess the financial stability of the medical scheme you’re considering by checking its Global Credit Rating (GCR). Ratings for the 16 largest South African medical aid schemes can be viewed on the GCR website.

Other important factors to research are their payout history and whether they have a reputable track record and brand.

6. Consider Your Age and Demographic in Your Decision

Are you over the age of 35 or 40? Depending on your medical credibility coverage, you may be forced to pay a late joiner fee if you are over these respective ages and have never had medical coverage. These can be up to 1.75 times the monthly contribution amount and are based on how long you went without coverage.

The older you get, the more coverage you will need. Consider what stage of life you’re in to determine what kind of coverage you will need. If you’re planning to start a family or expand one, you will need to look at which medical aid scheme has the best benefits for maternity and prenatal needs and coverage for minor dependents. If you’re a professional who travels often for work, some medical aid schemes offer products that cover your emergency medical costs and more when you’re out of the country. Your needs will become significantly more complex as you or your dependents approach the golden years, and you will need to factor this into your decision to choose medical aid coverage.

Age Domestic situation Financial situation Medical Needs
Youth to middle age
25 – 35 years ● You may have small children and perhaps have started to have older dependents such as your parents or grandparents.
● You may have a high amount of expenses compared to your disposable income.
● You may be looking for medical aid coverage for the first time.
● Probably prenatal, maternity and antenatal care.
● Family planning services.
● Possibly chronic and acute illnesses care.		 ● You may be at the beginning of your career and still learning to save and spend your money wisely.
● You may have a high amount of expenses compared to your disposable income
● You may be looking for medical aid coverage for the first time		 ● A few doctor’s visits a year. Probably emergency care.
● Probably prenatal, maternity and antenatal care.
● Family planning services.
● Possibly chronic and acute illnesses care.
Middle age to senior
35 – 65 years ● You may be living with a spouse and children of various ages.
● You may be living alone or with a spouse/long-term partner
● You may have several family members dependent on you financially		 ● You may have managed to save some money by now for your retirement, you are more aware of your immediate financial needs.
● You may have several family members dependent on you financially.		 ● Several doctor’s visits a year.
● Emergency care and more comprehensive medical and hospital cover.
● Prenatal, maternity and antenatal care.
● Family planning and fertility services.
● Acute and chronic illness care.
Senior to twilight years
65 and older ● You may be living with your older children, a spouse, alone, or with a caregiver. ● You may be in your last few years of working or have already retired.
● You are probably living off a retirement fund, pension fund and or the proceeds of a business.
● You may be providing financial support to your adult children, grandchildren and other immediate family.		 ● Multiple doctor’s visits per year.
● Chronic medication and illness care
● Hospice care
● Specific illness cover for diseases such as cancer and other terminal conditions.

7. Look Into Exclusions, Waiting Periods and Late Joiner Penalties

In reading the fine print, look for exclusions, waiting periods, and joiner penalties. It is normal for most medical aid schemes to impose these, and they affect what benefits you get from your coverage and when.

Exclusions

Some services, like cosmetic surgery and some dental procedures, are not covered by any medical aid plan. These lists of exclusions vary for each scheme.

Lower-cost plans tend to have more exclusions, as this is how they offset costs to provide a cheaper product. Find out what medical aid plans don’t cover procedures or services you may need now or in the future to avoid being let down.

Waiting periods

The Medical Schemes Act 131 of 1998 states that medical schemes are entitled to impose waiting periods on new members. New members pay full contributions to the medical plan during waiting periods, but they are not eligible to get full benefits from the plan. Medical aid schemes can impose waiting periods if you have a pre-existing medical condition, have never had medical aid coverage, or have had a break in medical aid coverage. Schemes normally impose waiting periods of around three months to 12 months for specific medical conditions.

Late joiner penalties

If you are older than 35, you may be charged a late-joiner penalty, which applies to people who only join a medical aid scheme at a later stage in life, depending on credible coverage.

You will have to continue paying this additional fee along with your premium as long as you remain on medical aid. Late-joiner penalties can range from 5% to 75% and will be levied on your monthly contributions.

8. Consider Gap Cover Instead of Upgrading

Gap Cover does exactly what its name suggests: it covers the shortfalls between what healthcare professionals charge and the medical scheme reimbursement.

We all know loved ones who have been suddenly sent to the hospital for emergencies and landed themselves in massive debt when medical aid funds run out or are limited for certain procedures. This is where gap cover comes in.

Many specialists charge private rates in hospitals (more than what the medical aid will cover), and that may leave you with a large hospital bill. Gap Cover offers extreme value and is very affordable, with most plans starting for as little as R250 per month.  With gap cover, you don’t have to worry about co-payments either. Consider it a backup plan for healthcare services your medical aid scheme can’t fully pay for. Check out our article on whether Gap Cover is right for you here. 

9. Research Managed Care Plans If You Have A Chronic Illness or Special Needs

Medical aid schemes typically try to reduce medical costs for long-term illnesses and patients with special needs. They do this by limiting members to network providers—a limited pool of healthcare providers from which to choose. Some medical aid plans will partner with certain drug formularies so that members can only buy medicines from certain pharmacies. This also helps keep costs down.

You may also find some schemes that provide special services for chronic and special needs patients, such as pre-authorisation mechanisms and special chronic condition programmes. You need to find out what each of these programmes offers and determine to what extent their programme meets your specific healthcare needs.

10. Consider the Advancement of Technology for Convenience

Medical aid schemes have kept pace with technological innovations that can save you time and money. In considering your options, you may want to check if any of them use advancements like apps that improve how you can communicate, submit claims, and access services from your medical aid. Through some schemes, cost-saving technologies such as telemedicine, which allows you to access doctor consultations remotely, are available.

You may also want to consider medical aid schemes that offer you rewards for making certain consumer choices such as having and using a gym membership, buying certain health products and foods and other such deals. These rewards programs could save you a few rands while offering you a little something extra compared to other medical aid schemes.

11. Speak to an Expert Healthcare Consultant

Brokers of medical aid can give you free advice on the best plans and choices for your needs and budget. You don’t pay a fee for services rendered by a broker in recommending a scheme or plan option. If the broker contracts with the scheme, the medical aid provider pays a certain monthly commission.

Cornerstone Healthcare Services provides expert, unbiased information about South African medical aid schemes. We can help you join a medical aid plan that best meets your health and financial needs.

As independent healthcare consultants, our advice is unbiased, and our main priority is to offer you a healthcare solution that’s cost-effective and most suitable for you and your family’s needs.

You can reach the Cornerstone Financial Services Group of companies by:

  • Vising our website here
  • Email us using info@cornerstonefsg.co.za
  • WhatsApp us on 068 018 0594
  • Calling us on (011) 794 4131

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Cornerstone Healthcare Consulting Services, Gap Cover, Healthcare, Medical Aid

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