How to make wise and healthy medical scheme choices for next year

4 Nov 2024

Medical aid members can upgrade to new plans within the scheme once a year. They can downgrade or switch to another provider all year long, but for all these choices it’s essential to do your homework first.

This is the time of year, just before the festive season hits, when you need to start thinking about your medical scheme choices for 2025.

Although it’s understandable that the kneejerk reaction is to look around for the cheapest scheme or the one with the lowest contribution increase, considering South Africa’s economic climate, this is a choice that needs to be more considered, taking several factors into account.

Since 2020, medical schemes have seen increased usage compared with the years when many people missed screenings for fear of contracting Covid-19. This has had two impacts. First, there has been an increase in the number of late-stage cancer diagnoses in the past two years, and second, this has translated to a higher number of claims being processed for larger amounts.

Although schemes had healthy reserves in 2020, quite a few opted to relay these benefits to members in the form of lower contribution increases. A review shows that many of them are now paying the price by having to implement higher contribution increases in 2025 to make up the difference.

A medical scheme is a pooled benefit – the funds belong to the scheme members under a non-profit structure. Under the Medical Schemes Act, all schemes need to have solvency reserves of at least 25%.

The increases of some of the larger medical schemes reflect mainly double-digit increases:

Bestmed: 12.75%;

Fedhealth: 12.4%;

Medihelp: 10.8%;

Bonitas: 10.2%;

Momentum: 9.4%;

Discovery: 9.3%; and

CompCare: 11% for principal members and 13% for beneficiaries.

Damian McHugh, chief marketing officer at Momentum Health Solutions, recommends making the most of preventive care services, wellness programmes and discounts on health-related products and services. “These can help to offset the cost of higher contributions,” he adds.

These are some of the questions to ask before you make a choice:

Do you or any family members have chronic conditions? All medical schemes have to offer you prescribed minimum benefits (PMBs), which include 27 chronic conditions. If you sign up for your medical scheme’s chronic plan, your medications will be paid out of the scheme’s risk pool and this ensures that your day-to-day savings are not depleted.

Is your doctor and/or local hospital part of the scheme’s preferred doctor network? Agreeing to use a service provider network that has been named by the scheme can reduce your medical scheme contribution by 15% to 35%. However, if you are considering this, research the accessibility of the preferred network in relation to where you live and work.

Your medical scheme will also pay only a portion of the bill if you use a provider that is not part of the stipulated network, and the scheme will automatically settle the bill directly with a network provider.

Have there been any changes to the rate of cover for specialists or doctors? For example, you might find that this year you enjoyed cover that reimbursed specialists at a rate of 300%. But this may drop to 200% in the year ahead, which means you will now face a co-payment.

Can you afford to handle waiting periods if any are applied because you are switching from one scheme to another? If you choose to switch from one scheme to another, you must apply for membership to the new scheme and you may face a three-month general waiting period. During this period no claims are covered, except the PMBs and chronic medicines.

You may also find that although all schemes must cover chronic medication, the new scheme requires you to use a generic or a product by a different manufacturer. Sticking to your original choice of chronic medication could mean you need to cover the difference out of your own pocket.

Have your requirements changed over the past year? You might be getting married or starting a family, in which case you will want to take a very careful look at the different options’ maternity benefits. Or your health may have deteriorated and you may find that you need a more comprehensive medical scheme benefit.

Do you need a medical savings account? If the health plan you choose has a medical savings account, you get an amount at the beginning of the year to spend on your day-to-day healthcare needs. The amount is available for the year and covers GP visits, spectacles and other day-to-day healthcare costs.

Does the scheme offer preventive benefits? On the back of the pandemic and the fact that lower screenings have led to higher and more serious dread diseases diagnoses, many schemes are now offering preventive benefits that include annual health assessments, pap smears, cholesterol tests and annual dental check-ups.

They may also pay for oral contraceptives from risk cover. Procedures such as MRIs and pregnancy scans may be paid from risk cover (out of the pooled benefit), whereas other schemes may consider this a day-to-day procedure. Ask upfront so you know what you are getting.

Are you active enough to want fringe (gym) benefits? A number of schemes offer value-added benefits such as reduced gym memberships and loyalty programmes that reward you for making healthy food choices when you shop for groceries.

Do you have sufficient hospital cover? Most medical schemes offer hospital cover of 200% to 300% of the medical scheme rate. Most plans will pay the hospital in full because of arrangements they have with the hospital.

However, specialists’ fees may not be covered in full, which could leave you out of pocket. Some schemes will pay specialists 300% of the medical scheme rate for emergencies, but only 200% for elective surgery.

Ensure that you ask all the awkward questions now and avoid awkward financial surprises later. DM

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

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