A Planned Procedure: What Medical Aids Cover

Medical aid members can save themselves significant amounts of time, money and effort this way. They should ask their medical aids the right questions, especially ahead of a planned procedure.

Understand what your medical aid can do for you before going into hospital for a planned procedure. And this way you will save on unexpected bills.

Jill Larkan, Head of Healthcare Consulting at financial advisory firm GTC, concurs with the Council for Medical Schemes (CMS). She says that members’ lack of understanding regarding their medical aid plans is one of the biggest reasons for members’ unhappiness regarding their level of benefits regarding a planned procedure.

The CMS said recently that the number of complaints from medical aid members had increased by 1 017, to 4536. That amounted to 29% during 2017-2018, compared to the previous year.

“This is in line with our experience as healthcare consultants to various businesses: unfortunately the majority of members do not attend medical aid presentations nor examine their medical aid policy with Planned Procedureenough care, even when they are aware of an upcoming planned procedure or specific treatment within the year. Members then realise – too late – that their medical aids do not cover certain procedures or costs,” says Larkan.

“Medical aid members need to change their behaviour towards their schemes. The onus is on them to establish the extent of cover they qualify for, ahead of their planned procedure.”

Members may only change their plan, within the same scheme, once per year. However, Larkan says they can still protect themselves against unexpected expenses in the event of planned procedures.

“Generally speaking, members should ask their medical aid or healthcare consultant the following ten questions. That will give them a better grasp of their cover, and so avoid unexpected bills,” she says.

  • What type of plan am I on?

“Firstly, establish what type of plan you contribute to and communicate this to your doctor or specialist. This will give them an indication of the type of items or treatment they have cover for. They will know whether this includes in and out of hospital cover.”

  • What level of cover do I get?

“In addition to knowing which plan you are on, it is also important to understanding what level of cover – ranging from 80% to 300% – your plan offers for the various line items of your procedure. Importantly, if your plan gives 100% cover, this does not mean it pays for the entire cost of an item.” .

Medical schemes have set rates for treatments and consultations (representing 100% or the Scheme Rate). However, practitioners and hospitals often charge fees that are higher than these rates. Sometimes they charge up to or even higher than 500%. It is important to verify which rate your treatment and consultations are charged at. You should find out whether your plan covers the entire cost.

  • Am I responsible for part of the costs of my treatment?

“Once you know what level of cover your plan offers, find out if you must pay for part of your procedure. When you know what this cost will be you can plan for any co-payments. Note that these may be required prior to admission.”

  • Does my gap policy cover the shortfall of my medical aid?

“Perhaps you have medical gap cover. Do not assume that this will necessary make up for the entire shortfall that your medical aid does not pay. Gap cover policies differ in scope.They may only cover up to a certain level or multiple of the scheme rate. Members need to examine these policies to understand what, and at which rate, their gap policies will foot the bill,” says Larkan.

Furthermore: members should be cognisant of the demarcation rules introduced by National Treasury last year. That limits gap cover to R150 000 per member per year.

  • Does my hospital cash-back plan cover the shortfall of my medical aid?

“Similarly to gap cover policies, members should remember that the demarcation rules limit hospital cash-back pay-outs to R3 000 per day, or a lump sum of R20 000 per year. This can seriously affect a member’s expectation of cover for their hospital bills.”

  • Is my planned procedure covered by prescribed minimum benefits (PMB)?

“All medical aids are required to cover the entire cost related to PMBs, which are a set of 270 conditions defined in the Medical Schemes Act. If your procedure is one of these, find out which designated service provider(s) you must make use of. These are a medical aid’s preferred doctor, hospital, etc. for various PMBs. That qualifies you for unlimited cover. If you are not using the designated service provider, be prepared to cover the additional costs yourself.”

  • Do I have to go to a network hospital?

“Depending on the type of plan you are on, your medical aid may only cover treatments at hospitals which fall within their network. You should also determine whether your preferred or referred surgeon operates at the network hospital.”

  • Do I have to use a certain specialist covered by my medical aid’s network?

“Medical aids often have selected doctors and surgeons in their networks, these are covered at the scheme’s full rate. If your practitioner is not on your medical aid’s network, you may be liable for payment of a portion of the bill. That depends on the doctor’s rate,” she says.

  • Will I need an anaesthetist for my planned procedure?

“This may seem like a small item, but the cost of an anaesthetist is often quite substantial, leaving a hefty portion for your back pocket, if this is not entirely covered by the medical aid. Find out whether you will require an anaesthetist and whether they are in your medical aid’s network, as well as the level of cover you will receive.”

  • Will I need recovery treatment?

“Lastly, find out whether you will need after-procedure treatment, such as a physiotherapist, and whether your medical aid covers all or part of this cost.”

Larkan concludes: “Members contribute to a medical aid to manage their healthcare expenses and avoid having to pay for costly procedures out of their own pocket. Similarly, medical aids need to constantly manage healthcare costs ensuring they remain viable entities and provide suitable and sustainable benefits to members.

“Changes to plans and benefit levels is a constant within this environment, which means members have to be more vigilant in ensuring that the level of cover provided by their plan continues to meet their requirements. Assistance from your professional healthcare consultant and your own diligent attention to changes within the medical aid environment are the only ways to ensure that your medical aid continues to do what you need it to.”