Making it through the medical aid renewal season

According to research by Sirago Underwriting Managers, private health costs from 2000 to 2012 doubled in real terms, and the cost trends point to them doubling again by 2028.

‘There are many complex reasons for this upward trajectory. Key is the fact that unlike the pharmaceutical industry, there is no pricing regulation on healthcare provider tariffs. With South Africa facing a dire shortage of healthcare professionals, specialists can charge any rate, often more than 300% to 500% higher than the rate paid by medical schemes,’ points out Martin Rimmer, CEO of Sirago Underwriting Managers.

With costs likely increasing in 2022, what should you be considering when it comes to your medical scheme – particularly if you’re looking at changing it to make payments more affordable?

1. Chronic medication needs

If you or any of your dependents are registered for a chronic condition, you should check to see if you qualify to get your medicines under the 27 regulated chronic conditions, or if you pay for them because they’re an additional disease listing under the plan you’re choosing.

Rimmer explains: ‘Consider whether the premium saving on a lower benefit option is worth the cost of the additional chronic medicine which you may have to self-fund on a lower benefit option.’

2. Is a downgrade necessary?

Downgrading your medical plan will mean you’ll save every month on your premium. But does it still match your family’s needs? ‘When you pay less, understand that you normally receive less cover and benefits. Be comfortable with the level of risk you can afford to take on as out-of-pocket costs,’ says Rimmer.

3. Can you afford primary healthcare costs yourself?

If you’re opting for a hospital-only plan, make sure you can still afford the day-to-day costs like GP visits, optometry, and medication. Your plan is required by law to pay for PMBs (prescribed minimum benefits), but non-PMBs will be paid for out of your money if you don’t have a medical scheme savings account.

4. Gap cover

Gap cover is short-term insurance that will help to fund the deficit between your medical scheme’s tariff and the rates charged by your healthcare professional. Most medical schemes will reimburse doctors and specialists at 100–300% of the scheme rate, but some specialists are known to charge five times more.

Speak to a broker to find out if you could benefit from gap insurance.

5. Waiting periods

If you’re considering an offer from a rival medical scheme, ask whether any waiting periods apply if you switch.

According to Hippo.co.za, your new scheme is only allowed to impose a three-month waiting period if you have had a medical aid continuously for over two years and change plans with less than a three-month break. If you can’t afford to wait out the waiting period, consider changing plans within the scheme you currently belong to.