Your health care options: what to consider when choosing medical help?

It’s around this time of year that medical plans start posting their benefits, contributions, and enhancements for the next year – and the options can be overwhelming, especially since it’s often not easy to make like-for-like comparisons. There are currently 18 registered open medical plans to choose from, all with a variety of plan options ranging from entry-level network options to fully comprehensive options. Sifting through brochures and fine print can be time consuming and confusing, and as such, this article aims to highlight what to look for when choosing medical help.


At first, it is advisable to undertake a rigorous budgeting process to determine your affordability. Although medical aid is an expensive budget item, as a general rule, premiums for medical aid should ideally be no more than 10% of your monthly expenses. However, as medical inflation exceeds consumer inflation by 3-4% per year, you will need to factor your future affordability into the process. Once you are clear on what you can afford to pay for medical aid premiums, you should be able to narrow down your options.

What is important to keep in mind is that all medical aids are rigorously priced by teams of actuaries and health experts, so beware of simply going for the lowest premium. expensive, because you get what you pay for. If a premium seems a lot cheaper than other similar plans, make an effort to read the fine print and be on the lookout for low sub-limits, high co-payments, and tightly managed care that limits access to benefits. specialists.


Even if your past health is not an indication of what to expect, it is advisable to take stock of your current health and that of your dependents. Specifically, make a list of any conditions or pre-existing conditions that any member of your family has, as well as any medications or chronic treatments that you or your family are using. You can then compare the services offered to the specific needs of your family. If you don’t have children but are considering starting a family, you’ll need to look for a plan that covers pregnancy, childbirth, and postnatal care. Remember, you cannot upgrade your plan option during a benefit year. Therefore, if you are planning to get pregnant during 2022, be sure to select an appropriate diet for your pregnancy.

Hospital coverage

The costs of private hospitals are outrageous and generally unaffordable for the average person, which is why choosing the right hospital plan is so important. Remember, not all hospital plans are created equal. Entry-level plans offer in-hospital treatment in a limited network of hospitals only at up to 100% of the cost of medical aid – which sounds deceptively appealing. However, the doctors and specialists who treat you in the hospital are free to charge rates much higher than the rate for medical assistance, and you will be responsible for the difference. Also, be sure to determine the required copayments for hospital procedures, radiology, pathology, oscilloscopes, scanners, specialty dentistry, and specialist treatments, as many of these will be reimbursable expenses.

Financial stability of the scheme

Look for a medical regimen that has a good track record and a good reputation, and that has a reputable and trusted brand. Specifically, investigate the payment history of medical plan claims to make sure they pay reliably and on time. Some poorly managed medical assistants have slow claim processing and payment capacities, which is frustrating for both members and service providers – with many service providers choosing not to process such medical plans, resulting in is not ideal.

Levels of service

When it comes to medical help, service levels are very important, so do your homework. Specifically, learn about the efficiency of the customer call center, how quickly the phone is answered, how efficiently member queries are resolved without having to escalate, how quickly complaints are processed and paid, and how easy it is to reach someone. Find out who the Medical Aid Administrator is and what their reputation for customer service is.

Treatment protocol

Most medical assistants have managed care divisions, some of which are contracted out to third party managed care operators. Managed care is used by medical plans to reduce costs, while maintaining high quality of care, and these can be delivered through provider networks, provider monitoring, drug formulas, programs. chronic disease and pre-authorization mechanisms. While managed care programs are primarily designed to ensure members receive good quality and appropriate care, they can be frustrating if not properly administered. Find out who runs the medical plan’s managed care program, what their service levels are, and how difficult it is to access care. For example, do you need a referral from a general practitioner to see a specialist, or does your program allow you to refer directly to a specialist?

Plan demographics

Medical aids operate on a cross-subsidy basis where premiums from younger and healthier members are used to subsidize health costs for older and sicker members. Accordingly, it is important to determine the demographics and size of the medical plan, keeping in mind that size matters. The larger the risk pool, the more predictable the claims will be. Likewise, the higher the average age of the group, the greater the financial risks. Also, check plan membership over the past three years to determine if there has been a significant loss of membership and, if so, why.

Increase in annual contributions

It is also important to determine whether the annual increases in plan contributions have lagged behind the rest of the industry. Again, look at the increases in plan contributions over the past three to five years. If they have always been above the market average, ask yourself why and be careful.

Technological innovation

Determine how well the medical plan has kept pace with technological innovation, making it easier to interact, submit claims, communicate and interface with the service provider. State-of-the-art medical aids provide users with apps through which members can track their benefits, submit claims, find healthcare providers, connect with doctors online, and participate in mobile chats. Make sure your medical aid has kept pace with technology and offers user-friendly technology for your convenience.

Loyalty programs

While loyalty and rewards programs seem appealing, avoid making a decision based solely on how attractive the program is to you. Remember, you are looking for good and reliable health coverage first and foremost, so keep that in mind. While the perks and rewards offered by these programs may seem appealing, these programs are only truly beneficial if you are fully engaged in all aspects of the program, stay on top of their enhancements and qualifications for the rewards, and consistently use your skills. advantages .

Chronic conditions

While most medical aids offer chronic disease benefits, it’s important to determine how well their program meets your specific healthcare needs. The medical aid brochure or website should include a list of all conditions covered by their chronic disease program, as well as a list of drugs approved on their formulary. Some plans also offer specialized programs for conditions like diabetes, cancer, HIV, and asthma, and it’s worth doing your research to determine if these programs will benefit you financially.

If you are having trouble choosing medical aid or are considering switching to a different medical aid, it is advisable to seek advice from an independent health care advisor who can walk you through the process to ensure you find a solution that is right for you. works for you and your family.