Choosing a medical scheme on a tight budget

Question

I am looking to join a medical aid scheme after not being on one for the past two years.  I'm 39 with a young child and can only pay around R3 500 a month. I'm looking for the following:

• comprehensive hospital cover


• sufficient day-to-day savings


• GP visits


• dental cover


• mental health benefits

In addition, I would like to have my hearing aids covered and be able to join a gym at a discount.

Answer

Over the past year, the contribution increases for medical schemes have far exceeded consumer inflation.  The R3 500 budget will be a challenge, especially after the recent increases. The traditional medical schemes of 20 years ago that offered unlimited visits to hospitals, doctors and dentists no longer exist.  There will be out-of-pocket expenses. At the risk of oversimplifying a complex industry, what is available to you now is:

• a core of medical cover that will pay out if you need to claim against a prescribed medical benefit. These are the 271 defined diagnoses and 27 chronic diseases that all medical schemes must pay for;


• the payment of a percentage (usually between 100% and 300%) of your costs when you are in hospital.;


• other expenses paid by yourself or some kind of medical savings account.

Most medical schemes offer an entry level benefit option where the contributions are lower, but you are likely to be restricted in terms of which hospitals and doctors you use, and where you collect any chronic medication.  If you use providers outside of these networks, then you will have to make a co-payment.

What I would recommend is that you look at the networks that are offered for the entry level options of the different medical schemes and see if the hospitals and doctors that are part of the network are close to you. Each medical scheme has a different network so look for the medical scheme that can provide you with the hospitals and doctors that are closest.

With the entry level benefit option, the visits to the doctors and dentists may require a small co-payment each time you visit them.  The benefit does not cover specialised dentistry so you would need to make allowances for that in your budget.

I have not found an entry level medical scheme benefit that covers hearing aids so you would need to budget for that separately.

If the mental health condition is classified as a prescribed minimum benefit, then it would be covered by the scheme with certain limitations regarding in-hospital and out of hospital benefits. Depression is a prescribed minimum benefit, which means schemes must cover it and costs are paid out of the risk pool rather than your medical savings.

Most of the medical schemes have programmes that encourage you to keep healthy. You should be able to find one that includes a discounted gym membership as it is in the scheme’s best interest to keep you healthy.

I would recommend that you contact a medical scheme broker who can compare the options of the different medical schemes.  You would need to find the scheme that offers the most convenient network of medical suppliers at the right price.  There will be compromises that will have to be made and it is important that your choices are informed.

Insider tip

If you change cities, remember to check that the network of medical providers that you are linked to is still the most appropriate one. You do not want to be in a situation where you have to drive 30 kilometers to the nearest medical practitioner on the network.

Kenny Meiring MBA CFP ® is an independent financial adviser who helps people put investment and risk structures in place to live wonderful lives.  You can contact him on 082 856 0348 or at Financialwellnesscoach.co.za. Please send your questions to [email protected]

Kenny Meiring is an independent financial adviser. Contact him on 082 856 0348 or at financialwellnesscoach.co.za. Send your questions to [email protected].

This story first appeared in our weekly Daily Maverick 168 newspaper, which is available countrywide for R35.