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MANAGE THE COSTS OF YOUR MEDICAL AID TO MAKE THE BEST OF YOUR COVERAGE

Dr Mike Marshall, executive manager: research and product development at the AfroCentric Group, offers five critical tips to help South Africans make the most of their medical aid.

The cost of living has run rampant in 2022 and South Africans are desperate to cut costs wherever they can. While the COVID-19 pandemic saw individuals do their utmost to hold on to their medical aids, the worst of the pandemic is over and many people may be considering either exiting their medical aids or reducing their cover.

But according to the AfroCentric Group, your medical aid is the last thing you should be cutting back on. "Making hasty decisions about medical aid membership could cost dearly later on, so we urge scheme members to think twice before altering their medical coverage," says Dr Mike Marshall, executive manager: research and product development at AfroCentric Group.  

Dr Marshall says there are ways to manage the costs of your medical aid so that it does not hit your pocket. This will ensure that you make the most of your medical aid without going too far out of pocket even when day-to-day savings have run dry.

Get the right plan for your medical needs

By understanding the benefits offered by your medical aid, Dr Marshall says you can make sure you are on the correct plan for your medical needs. "If you are over-insured, you are paying a premium for benefits you don't need. If you are under-insured, you will end up having out-of-pocket expenses on co-payments."

Dr Marshall says long-term treatment plans, such as full-course cancer treatment and the cost of care after disability, are often not always fully covered by medical schemes and need to be considered when assessing your cover.

"If you are on a savings plan and hardly use the savings or have accumulated a large amount of savings over prior years, then you could consider moving to a cheaper hospital only plan or a cheaper plan that has a lower savings component," advises Dr Marshall.

Don't incur late joiner penalties

Dr Marshall says a late joiner penalty (LJP) can be imposed on members over the age of 35 and can vary in cost depending on the number of years that they have not belonged to a medical aid.

"A late joiner penalty is a calculated percentage that is added to the member's monthly contribution and is incurred for life, even if you move from one scheme to another."

Dr Marshall says schemes generally apply LJPs if a member has never had medical aid or if they had a break in medical aid cover for at least 90 days.

Understand the intricacies of co-payments

It goes without saying, not all procedures or treatments are fully covered by medical aids. Rates are determined by the medical aid scheme, and you will often have to make a co-payment from your own pocket – especially if you use a provider not included in the scheme's designated list of providers (‘network'). This can prove unnecessarily expensive in the long run.

"Read up on the medical scheme's network of providers and hospitals associated before deciding on a plan. Medical aids negotiate special rates with doctors and specialists who are on the network which is why co-payments are often applied when using out-of-network providers. If your family doctor is not on the list, they are also welcome to become part of the network, so feel free to encourage them to join before visiting."

Utilise your pharmacist or telehealth

Pharmacists can provide sound medical advice on issues such as rashes, colds and minor ailments. "You can buy over-the-counter medication and treat less serious illnesses yourself with the help of your friendly neighbourhood pharmacist and save your medical aid savings.

"Remember that your savings should be there to cover your medical costs such as visits to the doctor as well as prescribed medication that may come at a higher cost than your average cold and flu effervescent or nasal decongestant."

Savings could also be achieved through telehealth consultations with your doctor which also offers the convenience of not needing to leave your home or office.

Manage your chronic conditions

Being diagnosed with a chronic condition can be stressful because chronic medication can be expensive. Dr Marshall says this is mainly because it needs to be used over a long period, or in some cases, indefinitely.

However, if your condition isn't registered, the cost will come out of your acute or savings benefit and once that's depleted, it will come out of your pocket. When this happens, Dr Marshall warns that it may be tempting to skip a few prescriptions or worse, stop using your prescription altogether – which can create havoc with your health.

Instead, Dr Marshall says, "Register your chronic condition so payment for your medication can be made from risk and not your savings. Ask your doctor to prescribe medication on your plan's formulary and obtain this from a network pharmacy or a designated service provider to avoid any or all co-payments."

Contact a broker

Dr Marshall says there are numerous other ways in which people can efficiently utilise their medical aid. "Depending on who you are, your life situation and your number of dependants, you are probably going to find numerous ways to get the most out of your medical cover."

Dr Marshall says it is worth checking with your financial advisor or broker if your scheme has an Efficiency Discounted Option (EDO) available on your plan. He says EDOs offer the same level of benefits, but at a discounted price if you are willing to limit yourself to using network providers.

"This is why it is important to speak to a broker who can help you determine exactly what you need and how you can get the most value for money in a tough economic climate," concludes Dr Marshall.