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10 Tips to help you choose a healthcare plan that suits your needs and, most importantly, your budget.

What to be aware of before you choose a medical aid plan.

If you can afford a premium of more than R10,000 per month, then you can have a plan that pays everything!

If not, you need to know what healthcare plans are available, so you can do to choose the best plan for your budget.


1. WHAT TYPE OF COVER DO I NEED?

10 tips on choosing medical cover
The greater the benefits you want - the higher the premium you pay!
It is as simple as that!
So your first step is to find a plan that meets your needs and wants.

Please see my page on the Different Types of Medical Plans.

What is on offer from Traditional, New Generation with savings, hospital only and network medical aid plans.


A simple hospital benefit only plan will save you considerable premium!
You need cover for big accidents, illness or disease. Most people can self-pay day-to-day, out of hospital costs.

Decide upon a COMPREHENSIVE Plan (offers in and out of hospital benefits) OR a HOSPITAL ONLY plan, (where you pay all out of hospital costs).

Hospital plans are cheaper than a full medical cover and do provide chronic medicine benefits as well.
One plan even pays essential dentistry taking care of emergencies like fillings and extractions!

However, if you have high day-to-day needs, you will need to consider joining a comprehensive plan, as these will assist you in meeting your higher treatment-usage costs.

Medical schemes offer a variety of plans that differ in the in-hospital rate they pay for claims.

Plans paying at medical scheme rates cost less than those that pay at private rates (2 or 3 times medical scheme rates).
Private rate plans can still short pay in-hospital claims, because private providers can charge up to 5 times what the medical aid pays!

top up

What can you do to address this threat?

If you can use providers who have a payment agreement with a medical scheme, they charge what the plan pays. So, you should never experience an in-hospital claim shortfall.

Better still, buy a Top Up/Gap plan that will pay any in-hospital shortfall and co-payment.

Every medical scheme member should have an insurance-based Top up plan.
It is a vital part of having full in-hospital cover!
These are totally separate products to a medical scheme and will work with any medical aid.

Now consider joining a plan that pays at lower rates - with a cheaper premium - because the Top Up /Gap cover will pay any possible in-hospital claim shortfalls.

The "saving" from the lower premium plan, should pay for the Top Up plan and still offer a lower, overall contribution!

That, along with cover that pays up to 5 times medical scheme rates in hospital, is unbeatable!


2. WHAT ABOUT MY CURRENT HEALTHCARE NEEDS, PAST TREATMENTS AND COSTS?

look at your health

You need to know what level of benefits you will need from a medical aid. List your past hospital, specialist, GP, medicine, dental and optical costs, to get an idea of the benefits your plan must offer.

If you seldom need medical treatment, but need protection from unexpected high private hospitalisation, then all you need is a simple hospital-only benefit plan. Self-pay your out of hospital costs.
This way, you pay a lower premium than that of a comprehensive plan and that "saved" premium may well add up to more than any day-to-day savings fund!

If not, you may need a plan with a savings fund to help with day-to-day expenses. If you frequently see a GP, or you need expensive, on-going chronic care, then you may need to consider a fully comprehensive plan.

Consider any hereditary conditions, like glaucoma and other incidences of dread disease in your family. You may need full, comprehensive medical to cover these potential threats, rather than a hospital plan.
If you have an eye or dental problems, it is to best choose a plan that offers these as benefits.

how much can you affordOther questions you should ask .....

Not having at least hospital cover, is like driving a car without a spare tyre.
You will need it at some unexpected time and if you don't have it, you can be in serious trouble!

3. HOW MUCH CAN YOU AFFORD?

how much can you afford
Top-of-the-range medical aid is very expensive!
If you earn R6,000 pm, you cannot spend R2,000 on a medical premium. Simple!

There are plans that allow low-income earners to access private healthcare.

These plans offer no overall limit hospitalisation and mostly unlimited primary day-to-day care.

They give life-threatening (heart attack, car accident) and life-sustaining (kidney, cancer illness) cover - all for a low premium.
They are ideal for low-income families who need GP cover and pensions on a fixed monthly income.

An expensive medical aid will have better benefits than a low cost one.
But it is possible to find plans with good hospital cover and lower day-to-day saving funds - in turn, dropping your total contribution!

Here is an excellent scheme offering you the maximum flexibility in managing savings accounts and helping to reduce your overall premium!

The "trade-off" is that if you run out of savings, you pay day-to-day costs for the rest of that year. However, in many cases, there is a significant cost saving for you, when investigating these plans.

Some plans offer a safety net - in the form of unlimited network GP consults - if you do run out of funds anyway!

Some plans cover financially dependant children to age 27!

Please note that hospital insurance plans - that pay you per day you spend in-hospital - very seldom cover even a fraction of the medical costs!

We can help you investigate which scheme will give you the best rates for your partner and young adult children.

quote I want a quote.


4. WHAT ABOUT PREMIUM INCREASES?

afford healthcare plan

The cost of medical care is incredible.

Medical inflation is around 12%. That, added to running cost of schemes, has resulted in increases way above the CPI rate and salary increases!

Excessive and continuous annual increases indicate serious flaws existing in that medical scheme!
Schemes in 2021 have around a 8% increase in premium!

Unfortunately, there is little we can do about this, except try to reduce the cost of your medical cover.

One scheme boasts a 4.9% increase!


5. WHAT IS THE SCHEME'S CLAIM PAYMENT RECORD?

If you decide on a scheme, phone your GP, or the nearest private hospital, and ask them whether they have experienced problems with claim pay-outs from that particular scheme.

Check on the Internet for administrative and service concerns members may have posted. (Hellopeter or My Broadband etc. You certainly don't want to join a scheme that has a dreadful servicing record!

Investigate the scheme's solvency ratio, as you don't want to find out that the scheme has gone insolvent while you were in a hospital having kidney stones removed!

The Council of Medical Schemes is tasked with checking schemes comply with solvency requirements. Schemes should have at least 25% of members' annual contributions in reserve.

We can help you avoid joining a scheme that is not financially sound!

A scheme with large membership is more secure. If they lose 1,000 members, the effect on their solvency will not be as great as a small scheme that loses the same number of members.
Let us help you find that scheme!


6. HOW MUCH ARE THE OVERALL IN-HOSPITAL LIMITS?

overall annual limits
It is impossible to know how much hospitalisation may cost. There are so many factors that are involved, let alone the ever-increasing cost of care, that you cannot make a guess.

It is therefore vital you consider plans with no overall in-hospital limits.

In 2018 a day in intensive care required R 27,000. A family of four would require R 108,000 PER DAY or R 756,000 over a week.
And that is only the cost of a general ward, no specialist or treatment costs!

A no overall annual limit, in-hospital benefit is the minimum cover you should consider.

However, that does not mean that every cost in hospital is paid.
Benefits have sub-limits - as listed in the plan rules - and these can limit certain claims and lead to co-payments for you.
An example is cancer cover. A plan may say it is unlimited, but they levy a co-payment after a pre-defined amount is claimed.

Check the HIV cover as in South Africa, this is important.
What will the scheme pay should you become HIV-positive and, maybe require a lengthy hospital stay, or chronic medication?

7. HOW TO CHOOSE THE BEST MEDICAL AID PLAN.

best medical aid plan
In your 20's:
If you are a student consider the Best Student Medical Aid Plan. Very cheap premium with excellent benefits.

Or consider a Hospital Only benefit plan.

Young and healthy, you may have little need for doctor visits and medicines.

BUT, we live in a violent country and you do need cover for emergencies. catastrophic events (big accident, illness or disease) and maternity. You do not want to rely on your family to pay medical costs!

You are laying the foundation for your future health, so ensure you get preventative care benefits with your plan.


family medical aid plan
In your 30’s: look at an affordable cover for a family.

With children, you need a more comprehensive plan - hospital, GP, chemist, dentist and optical benefits.
These are expensive plans, so maybe consider a cheaper option, that uses network providers.

Prevention is better than cure, so you need regular dental, cholesterol, glucose and blood pressure tests.

Pregnancy is expensive! Your plan must cover you throughout pregnancy and birth. Consider a more comprehensive option before you plan to start a family.


mature medical aid plan
In your 40s, 50's and older: the more cover the better.

You need more comprehensive benefits.
Heart disease, cancer, osteoporosis and dread diseases develop during these years, so you need a plan which pays for chronic medication.

If you are prepared to use providers listed with a scheme, look at a network provider plan.
These schemes are good at controlling costs and then passing savings on to you through lower rates.

You may have a concern, because you can only use certain healthcare providers. However, if most of the listed network providers are easily accessible, it’s a perfect match.

Many network options offer full cover for in-hospital treatments, including specialists, and day-to-day benefits, giving you a more comprehensive benefit than you might expect.

INGWE Network Medical Plan - This plan offers an ANY hospital option as well!

KEYCARE Network Medical Plan - the most popular plan in South Africa.

If you feel you do not need expensive day-to-day benefits, then consider a hospital only benefit plan.

Hospital plans provide the same in-hospital cover as most other, more expensive medical plans.
They just do not cover out-of-hospital benefits like GP visits and optometry.
But, if you are a healthy person who visits the doctor or dentist once a year, that may not be such a problem.

Because a hospital plan is much more affordable than a comprehensive medical plan, you can use that saving in contribution, to pay for your out of hospital expenses. It may still be cheaper, over a year than joining a comprehensive medical aid!

Work out what you spend - out of hospital over a year - add 15% as a "bad luck" buffer and compare that amount, to the premium you save by joining a hospital only plan. I bet it will surprise you!

Here is a good medical aid blog


8. WHAT IS GAP COVER?

gap and top up plan

Gap/Top Up cover is the most affordable way to supercharge your current medical aid option - at far less cost than upgrading it!

Gap cover is designed to cover shortfalls between what your in-hospital healthcare providers charge and what your plan pays.
And schemes are increasingly adding procedure co-payments, which a Top Up pays as well.

Premiums for a good Top Up are around R 400 pm and you can buy from any company you want.
Top up insurance is a totally separate product from any medical scheme.


If you are not fully covered by medical aids these are some of the risks YOU face:

Not fully covered by medical aids.2020 shortfalls paid by Gap Cover.
Natural ChildbirthR 19,250
Caesarean Section ChildbirthR 29,645
TonsillectomyR 8,391
Hernia RepairR 35,632
Breast Cancer SurgeryR 54,158
Hip Replacement SurgeryR 61,730
Spinal SurgeryR 147,782
Cancer TreatmentR 120,240
Heart SurgeryR 165 654

For more detail on this very valuable addition to your medical cover plan, please read The Valuable Benefits of Top Up/Gap cover Insurance.


9. WHAT ARE THE PLAN'S EXCLUSIONS AND LIMITS?

Best you know before you join a scheme just what is NOT paid!

When you join a medical scheme, your application is underwritten the scheme and may add waiting periods. Anything from 3-months for everything, up to 12-months for specific conditions.

If you are already pregnant, the scheme will exclude your pregnancy for a year - but will cover your child from birth. You must be a member at that time.

Lower cost plans have more exclusions. Joint replacements, specialised dentistry and so on are not covered.

So, be aware of these possible exclusions before joining by making a point of reading the plan rules!


10. WHAT DOES A BROKER OFFER YOU?

When you join a broker-recommended scheme, you don’t pay a cent! The medical scheme pays a fixed monthly commission, provided the broker is contracted to the scheme.
If you do go direct, you pay the same premium.

So, why not use our skill and experience in this industry. For sure, most people will need help!

quote I want a quote.

TALK TO ME .... I am here to help you - AT NO CHARGE!
Send me your questions and concerns. I'll answer them for you.

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You must consult the schemes/company product brochures and rules for comprehensive benefit descriptions.

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Last update: May 6, 2021

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