Types of Medical Aid in South Africa

Hospital plans - ONLY offer in-hospital benefits and emergency service. You pay out of hospital costs - except the prescribed minimum benefits (PMBs) which include many chronic conditions. THESE ARE NOT INSURANCE-BASED HOSPITAL PLANS, which are very restrictive in cover!

Traditional option - pre-defined benefits and limits, from expensive, comprehensive plans to limited, more affordable plans. Benefits are in rands or fixed number of consultations and treatments.

New-generation options - in hospital benefits with a medical savings fund for day-to-day costs. You can spend the funds as you wish, within certain limits. The full annual amount is credited to your account at the beginning of the year. Any year-end balance is carried over to your next year. Once savings are spent you pay further costs that year, except with plans that have an above-threshold benefit. Then, once your claims have added up to a pre-determined amount and your savings are used, the scheme pays further costs that year. Some thresholds are limited. Some plans require a co-payment as well.

Network options - you choose to use providers linked to the scheme and get discounted premiums. Networks of hospitals, doctors, pharmacies, optometrists and dentists. This does no mean you receive sub-standard treatments. A good network medical scheme should ensure that it contracts with practitioners who provide quality care, and that its members claims will be paid in full. Most premiums are related to your income, so those with lower incomes can still belong to a medical plan. Ideal, affordable plan for pensioners and families on a strict budget!

How to Choose the Right Plan that comfortably suits your needs and pocket.

What can you afford to spend? If you pay over R10,000 per month and you can have a medical aid that pays everything! But for most of us that is impossible so, you need to know what you can comfortably spend on your plan.

What cover do you need? The greater your benefits - the higher the premium! So it is vital you have an idea of what you want from a medical plan. If you are happy to get a plan that does not have all the "bells and whistles" (say a hospital only plan), you can save considerable money!

100% or 200% of scheme rates. At the beginning of the year medical aids meet with providers to determine a basic rate for services. This is known as the medical aid rate or 100% of scheme rates. But, private providers can charge up to 5 times this rate. More expensive plans pay up to 2 times this rate, reducing any potential in-hospital shortfall you may incur. Schemes also now offer the use of listed providers, in which case your costs are paid in full.
However, there is always a threat of a shortfall with claims. And many schemes are also introducing co-payments for certain in hospital procedures.
You are strongly advised to consider a GAP or TOP UP insurance plan to address this threat.

young personIN YOUR 20'S: CONSIDER A HOSPITAL ONLY 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 and trauma 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.

IN YOUR 30’S: LOOK AT AFFORDABLE COVER FOR A FAMILY. With children, you need a more comprehensive plan - hospital, GP, chemist, dentist and optical benefits. But, these are expensive plans, so 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. Medical schemes will not cover pregnancy if you have already conceived.

IN YOUR 40S, 50'S AND OLDER: THE MORE COVER THE BETTER. You have the need for more comprehensive benefits. Heart disease, cancer, osteoporosis and dread diseases develop during these years, so you need a plan which pays for chronic medication.


Are you, like so many medical aid members, struggling to meet the high cost of your medical aid plan?

Here are some ideas to consider that may help you keep your medical aid.

Your biggest financial risk is the cost of private hospitalisation. You cannot compromise on this!

Next highest expense is normally in and out of hospital dentistry. Again effective cover is a must!

Lastly doctor, chemist and glasses, which you may be able to self-fund through your own savings plan.

The answer is to consider joining a lower benefit and cheaper plan.

The greater the benefits of a plan, the higher the costs.
So, consider cheaper options that have smaller medical savings plan or no savings plan at all.


Whatever you may do, never be without hospital cover!

What to consider when taking out a hospital plan.
Make sure it covers casualty, any admission and certain legislated chronic conditions.
You also need annual screening and diagnostic tests, procedures and specific vaccines out of hospital (Mammograms, cholesterol tests, prostate tests, flu vaccinations and immunisations for babies and toddlers). Ensure you have professional and extreme sports cover, if you lead an active lifestyle.

If you want some out of hospital benefits, the Smart plan offers unlimited, network hospitalisation and a co-payment should you need a network doctor, medicine, dental and optical treatments. The best of both worlds!

What to consider when taking out comprehensive cover.
A tooth filling, can set you back by up to R8 000, so it may be worth investing in a more comprehensive plan? These plans offer unlimited in-hosptal cover and a savings account from which you pay all out of hospital costs. It is vital you have a reasonable enough savings amount for the year. More expensive plans have a safety net, should you run out of savings.

What to consider when taking out a network plan.
Most network plans have income-related premiums. The less your income - the less your contribution and can be a lot cheaper than a comprehensive plan. Network plans offer mostly unlimited hospital, day-to-day and chronic benefits through a network of providers. They cover PMB conditions as well. There is a trade off in terms of your choice of hospital or doctor, but you pay lower premiums.

young personGAP or TOP UP Insurance. Medical plan pay claims at different rates. This can result in a shortfall with your claims.
To stop this happening to you, you can use providers linked to your medical scheme as they charge what the plan pays OR, buy a Top up/ Gap cover plan. This helps you meet in-hospital claim shortfalls. This is really the best option.
There are also procedure co-payments like diagnostic scopes and specialised dentistry. These will be taken from your savings (if you have any at the time) or you will have to pay them. The Top Up will pay any scheme related co-payments for you.

A medical aid does not guarantee that you won't have to pay money towards medical costs!
You really need to cover possible in-hospital shortfalls and co-payments as these can be substantial.

How to Choose the Best plan.

Some question you should answer.....You may feel you don't need medical aid but, to not have - at least hospital cover - is like driving a car with no spare tyre. A high risk!
A 20 year old who hasn’t seen a doctor since birth needs something quite different from the 50 year old with high blood pressure and diabetes!

Medical Aids only allow plan upgrades at year-end - ALL EXCEPT ONE! If you suffer a life-changing event (from pregnancy to cancer) you can IMMEDIATELY upgrade your plan.
So you can choose a cheaper plan, safe in the knowledge that, if you need better benefits, you can get them!

Join a good plan before any serious illness strikes. Look ahead 5-years to try assess what cover you’re likely to need, track your health history and consider any genetic factors that may play a role.
Ask me for independent advice to help you choose the right medical scheme package.

The scheme must be financially stable. Check their claims paying ability and solvency level.
Remember, the more members - the better the scheme! So choose from larger medical aids.
We only offer plans from the top 5 schemes.

Don’t choose a plan purely on cost. Identify what it is you need, then look for plans that best meet those needs. Be realistic about the state of your health and don’t bank on the invincibility of youth, or your current state of good health lasting forever.

Compare costs and trim your plan to your budget. You must get quotes before joining a scheme and this is not always an easy or understandable process! We try to make this as easy and simple as possible. USE US!
I do not charge and additional fee! You pay the same as if going direct, but I have years of experience in this field. You run a real risk “cutting out the middleman!” Especially where it costs you nothing extra!

You need to know about exclusions, limits and implications of the scheme’s network of doctors. We provide the information – all you need to do is READ IT!
It is in writing, so there is no misunderstanding. And you can see that discussion ….anytime!
We are just an email away. We will respond far more quickly than getting a broker appointment.

Avoid Hospital Cash Plans. They are insurance products, not bound by the same rules medical aid schemes have to meet. They pay fixed cash benefits and can be extremely restrictive when claiming - very unlikely to meet more than a small fraction of your actual costs. Get an in-hospital only medical plan because, claims are determined according to the actual healthcare expenses you face and not on a pre-agreed, daily cash sum. Far more secure.

Don’t be drawn in with wellness and loyalty programmes. They are not the reason you are buying a medical aid and you pay to belong to the programme. To get reasonable rewards costs money. A free rewards programme is worth what you pay for it! However, some wellness plans are worth it, if you are dedicated enough to use them properly. Again, talk to me for help in making a decision.

If you do your research properly and get professional help, you can choose a plan to best suit your needs. Then you won’t be disappointed when claiming, because your expectations will be met.


How do I join a medical aid?

These are complicated products. They used words that we do not understand.
Make your life simple and get hold of us. We will email you the application with instructions on completing it. Return it to us and we will check and send it to a dedicated team we have within the medical scheme. We will track it and assist with problems all the way through to getting your certificate. FOR FREE! You pay what you would going direct as, the medical aid pay us our fee!

You may think that you’ll never need medical cover, but considering that one episode in a private hospital can set you back hundreds of thousands of rand, is it not better to pay a small monthly contribution to ensure you are covered?

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