Medical Scheme Tips and Tricks

Medical scheme members should aim to get as much legitimate value out of their medical aids by examining and understanding the medical aid scheme they belong to and making changes if necessary.

It is sometimes difficult to understand your scheme. However, the longer you belong to any one scheme and the more you examine the paperwork  and online details relating to the medical aid option you are on, the better you will get a picture of what your medical aid covers and what it does not.

This is the certain way to ensure that your medical scheme claims get paid out as expected.

 

 

Tips & tricks circular icon on white backgroundHere are 10 points to find out about your particular medical scheme option.

1.    Is pre-authorisation necessary before a beneficiary is admitted to hospital? Find this out before an emergency occurs.
2.    Do you need pre-authorisation to undergo complicated and unusual procedures such as weight loss procedures, abortions, etc. and expensive procedures such as chemotherapy and heart operations?
3.    Do you have to use particular doctors, specialists and health care facilities in accordance with the medical scheme rules, or can you use any one you like? Be sure to get the list of health care providers in the case of the former.
4.    Does your medical aid require you to consult a general practitioner (GP) before going to a specialist? You don’t want to be saddled with unexpected specialist costs because you did not follow the scheme rules.
5.    Does your medical scheme cover dentistry? A lot of options leave out this important component. Be sure to ask your scheme what the position is, especially regarding specialist treatment such as root canal work, crowns and implants.
6.    How much did your medical scheme pay out in claims? Find out by visiting the website of your particular medical scheme. You will be amazed at the millions paid out in schemes. That should give you peace of mind that your claims will be paid, as long as you abide by the rules of the scheme.
7.    Is your medical aid competitively priced? No matter what medical scheme you are with, we suggest you make a list of the five major benefits of your scheme and compare this with at least five other schemes’ comparable schemes to see if you could save money by switching. We recommend you check your scheme against comparable options at Discovery Health, Bestmed, Genesis, Selfmed, Momentum and Fedhealth. Phone their help lines if necessary.
8.    Go to the Council for Medical Schemes website at http://www.medicalschemes.com/ and look at the CMS annual report to find the level of your medical fund’s reserves, how many members your scheme has, how much was collected in premiums, how much was paid out in claims and whether it has an operating surplus. Remember that medical aids are non-profit organisations.
9.    Have you got too much cover? If you are young and healthy you might not need comprehensive medical aid. Consider other options.
10.    Do you need further advice? If you are at all unsure about the details of your medical scheme, contact an independent broker or call the medical scheme help line to get expert help.