Annual checkup for health plan

Just as thoughts turn to year-end holidays and festive fun, along comes that annual medical aid letter to force us back to earth with a bump.

It's the one that puts you on notice to change your scheme plan for next year within a certain time period - or forever hold your peace. (Well, at least for another 12 months)

Count yourself lucky if you have no need to upgrade or downsize your medical cover next year; you can ignore the request. The rest of us, for reasons that vary from financial strain and growing families to sudden illness and age-related disease, have to make a decision.

And that's easier said than done for many. It's no secret that most of us struggle with scheme terminology and jargon.

And despite new legislation demanding the use of plain and understandable language, documentation outlining medical cover is still too complex.

In making a new choice for 2012, key issues to consider are affordability; when you ran out of money this year; what each family member's health status is currently; what new or ongoing chronic medication is needed; and what changes the coming year holds for your family that could possibly change your risk profile.

Unfortunately health, like most things in life, is unpredictable. None of us knows what illness may befall us or what emergency hospitalisation may be needed.

Options range from costly comprehensive plans that provide blanket (well, closer than most) cover for the year, to middle-of-the-road "network" plans that limit you to certain providers and GPs, to the lowest, hospital-only cover.

Then there are top-up plans, which pay the difference between what the scheme pays and what some providers charge in hospital. These can provide a safety net, especially if you're on one of the lower options.

Either way, medical cover is expensive - research done by Discovery Health last year showed that an average family of four could spend the same on medical aid every month as on car or bond repayments.

So it's worth making use of an agent or broker linked to your medical scheme to help you navigate the options.

You can also seek general advice from an independent and accredited financial adviser.

But do your homework first; ultimately it's your responsibility to know what you're paying for.

To help this process, Discovery Health's head of research and development, Alain Peddle, offers some tips on making sure that the product you buy matches your needs.

Think about your needs in terms of:

• Choice: medical schemes are often able to secure favourable rates for their members within a network arrangement, by using formularies (set lists of drugs and treatments for certain conditions) or by placing limits on certain benefits. Some consumers want to be able to choose freely which doctor they see, which hospital they'd like to go to and they're prepared to pay for that choice. Others are happy to pay less to get the best price;
• Price: how much can you afford to pay every month for medical aid and how high a priority is medical aid for you? If you are young and healthy, your medical aid is probably less of a priority and you may be happy to pay and get less. If you're older or in poor health, you may be prepared to cut down other expenses to spend more on medical aid; and
• Comprehensiveness of cover: again, this is related to your age and health status, and the needs of your family. Young, healthy people and people with no or few financial dependants typically need less cover. If you're older, in poor health or have a large family, you may need more comprehensive cover.

Once you've decided, here's how to stretch your benefits:

• Understand what you're covered for and at what rates. Refer to the material you receive from your medical aid, use its website and talk to your broker;
•  Ask upfront what rates your doctor charges and whether or not you'll be liable for any co-payments;
•  Tap into any network arrangements your medical scheme may have. Some medical schemes have network arrangements in place that pay doctors directly, reduce administrative hassle and keep costs down;
•  Pay cash for over-the-counter medicines. Don't claim for everyday headache tablets, cough preparations and so on. Paying cash will make your savings account last longer, so you have funds available for more serious, expensive out-of-hospital treatments;
•  Ask your doctor and pharmacist for generics if available. Generics have the same clinical benefits as branded drugs - they have the same active ingredients - but are usually far less expensive;
•  Shop around for the best price. Find out whether your pharmacy charges the lower dispensing fee recommended by the medicine pricing regulations, or a higher rate;
•  When you are going into hospital, having any procedure, or discover you're pregnant, get pre-authorisation;
•  If your medical scheme offers an emergency response service, save the number on your cellphone;
•  Make use of any advice lines and counselling services your scheme offers;
•  Check if your medical aid offers travel insurance for medical expenses when you're travelling overseas; and
•  Find out if your medical aid offers you preventive screening benefits and wellness tools.

If you haven't taken advantage of your scheme's annual screening benefit, you've got a month left to do so.

Sunday Smile

To the New JustFun Group, which couriered a new set of letter tiles to Scrabble addict Yvonne Spain after her set, bought in July, faded and became illegible. "I told them that if my marriage could survive the sweat and tension of their board game, so should their tiles," said Spain.

Sunday Snarl

At Checkers Tokai for charging R130 more than the R119 shelf price for each of two Barbie mermaid dolls - and then refusing to give the second one at the lower price. Pensioner Heather Anderson refused both, and took her money to Pick n Pay Long Beach which sourced two similar (unbranded) mermaid dolls for just R79 each.