Is Your Medical Aid Sufficient Health Cover?
Usually people find out that their medical aid cover is insufficient only when it is too late and they are faced with high medical bills for hospitals, doctors, specialists, medication and so on.
This short article aims to help you establish if you medical aid cover is sufficient before you are faced with what the industry refers to as a “self payment gap”.
When Medical Aid Isn’t Enough
When medical aid cover falls short it is usually for one or more of the following reasons:
- Your medical savings account runs out of funds
- You exceed the benefit limit of your scheme. This is a complex area, with each medical aid plan having benefits and sub-benefit lists
- The doctor you choose charges more than the scheme allows for
- The medical aid scheme says that your condition does not fall under the Prescribed Minimum Benefits (PMBs). There are nearly 300 of these, including 27 chronic conditions that your medical aid is prescribed by law to cover all treatment for
- You exceed your medical aid’s limit on managed care relating to illnesses such as asthma, cancer, etc.
- You elect to undergo certain procedures or buy certain medicines that your medical scheme has nominated as being “self payment” items, for which the medical aid member will have to pay a percentage
- You have cancer. In most cases there is a wide diversion between what the medical aid can offer in terms of PMBs and the amount charged for treatment
- You require replacement body parts e.g. hip and kneed replacements, heart transplants or medical equipment such as wheelchairs. You then find that your medical aid can’t pay for the best
- You need an organ transplant and discover that your medical aid won’t pay for it as it is not included in your scheme
- You need lengthy rehabilitation and find out that your medical scheme does not pay for it, or pays for it only partially
What to do
There are a number of ways to ensure that your medical aid will be sufficient
- Make sure you understand exactly what your current medical aid scheme covers and does not cover. Increase the cover where necessary and make sure you have the option to upgrade later to include organ transplant cover.
- Before you visit a doctor, enter a hospital or buy medication, liaise with your medical aid to find out what they cover and choose accordingly
- Increase the amount you allot to your medical savings account. This could help you in future when faced with cancer treatment, replacement body parts, rehabilitation, etc.
- If you have any condition listed in the PMBs, insist that your medical aid covers the treatment in full. If they refuse, you can appeal to the Council for Medical Schemes
- Consider buying into a Hospital Plan or purchase Gap Cover to cover any shortfalls between what your medical aid will cover and what the treatment really costs