What do you look for when choosing a medical aid plan? This is a question that many consumers struggle with.
Joining a medical aid scheme is expensive and therefore a grudge purchase that consumers don’t like to pay, especially if they and their family never get sick.
They only realize the value when someone gets sick, as many have during the pandemic, or when a family member is injured in an accident. Choosing a medical aid plan is not something you do lightly and you should approach this important decision with caution.
You need to make sure you can afford membership and get the coverage you need, so keep the following tips in mind.
Check your budget
This can be an expensive exercise, so you need to look at your budget to see how much you can afford per month.
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What do you require from your medical assistance plan?
To determine what you need from your medical assistance plan, the answers to these questions will help you: Are you single or do you have a family that needs medical coverage? How old are you and your spouse?
Do you have children and how old are they?
Are there any hereditary diseases in your families?
Do any of you have a chronic illness that requires ongoing treatment, or is your family healthy and following a healthy lifestyle?
Does your child get sick every winter?
Ask people you know about their medical coverage
Ask your family, friends and GP if they are happy with their medical aid schemes.
Are you asking if their claims are paid promptly or do they have to spend days on the phone settling an unpaid doctor’s account?
A good medical aid plan pays on time and has good guidelines that clearly state what it pays.
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Ask an expert
Once you have decided to join a medical assistance plan, make an appointment with a medical assistance plan broker, because it is important to talk to someone who does not want to sell you membership to a specific diet, which can help you choose the right one for your needs.
View Medical Assistance Plan Reserves
Medical aid schemes must, by law, have at least 25% of their members’ contributions in reserve and must invest these to ensure funds are available to pay claims.
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What does the Medical Assistance Scheme offer?
You have to be careful of medical aid plans that make huge promises with many benefits, but when it comes to paying the claims, they offer very little with many exclusions.
Consider the daily limits and annual amount of your medical savings account. For example, if you have a child who gets sick often, your benefits could run out by April if the savings account provides only a small amount.
Also look at how much you will have to pay out of your own pocket, compared to what the plan will cover.
Consider the hospital benefit amount and see if you will be limited to specific hospitals and if so, if one of those hospitals is near you. The ideal is to choose a fund offering 200% of the fund rate for hospital care.
If you need to get medical cover for a family of four, a medical aid scheme that pays R600,000 per family per year won’t be worth much, as many families have seen during Covid when families whole had to be hospitalized.
Cancer treatment is also an important factor. How is cancer treatment determined and will the Medical Aid Scheme pay for further treatment if a member of your family develops cancer?
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Medical assistance plans generally have two exclusions: exclusions for less than one year when you are a new member and exclusions for an indefinite period.
You should check these exclusions first and make sure you are happy with them before joining any medical assistance plan.
Wouldn’t a hospital plan be better suited?
Although hospitalization plans are often more affordable than joining a medical aid plan, you should remember that a hospitalization plan only pays when you are admitted to hospital, under certain conditions.
A hospitalization plan only pays to cover lost earnings and not for direct medical expenses.
Direct medical costs can be much higher than the amount paid by the hospital plan.
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Medical assistance plan or medical insurance?
Your medical aid plan pays for medical conditions up to plan rates, but health insurance, like all insurance products, will pay a fixed amount if something specific happens to you, instead of paying specific amounts. for specific medical services.
Medical insurance covers loss of income and unexpected expenses, but not direct medical expenses. Medical expenses can also far exceed these contingency expenses.
Medical aid schemes and medical insurance providers are controlled and governed by legislation and statutory regulatory bodies.
According to the Medical Plans Act, certain medical conditions and emergencies, called Minimum Prescribed Benefits (PMB), must be fully covered by medical plans regardless of the type of plan you have, but medical insurance does not have this requirement.
There are over 300 PMBs which include emergencies, most cancers, and 27 chronic diseases such as asthma and diabetes. Health insurance benefits are not guaranteed by law.
Medical assistance plans also offer open enrollment and community assessment. Anyone can join a plan of their choice and cannot be turned down, and all members pay the same monthly fee for the same benefits under the plan option.
With medical insurance on the other hand, your premiums are determined by the state of your health. If you have a pre-existing medical condition, you’ll pay more for medical insurance coverage, and you may even be denied coverage if you’re too risky.
Medical plans operate similarly to a non-profit, member-benefit mutual organization governed by a board of directors. Medical insurance is provided by long-term insurers owned by shareholders who expect a profit.
Medical insurance is considered long-term insurance and is therefore regulated by the Long-Term Insurance Act enforced by the Financial Services Board.
Medical aid is governed by the Medical Schemes Act, which is enforced by the Medical Schemes Council. This means that your consumer rights regarding medical aid and medical insurance are different.