Why join a medical aid in SA, and tips for switching medical aids

Medical aid in SA provides financial cover for medical expenses for members who pay a monthly contribution for this cover. Medical aid covers members’ health-care costs such as hospitalisation, treatments and medicine. These costs are covered according to the rules of the medical scheme and the member’s medical aid plan type. These rules ensure that members are fairly cared for.

All medical schemes in SA are governed in accordance with the Medical Schemes Act 131 of 1998, and are regulated by the Council of Medical Schemes.

Medical aid contributions paid to medical aid schemes (including Discovery Health Medical Scheme) are pooled and safeguarded. These schemes are operate on a not-for-profit basis.

Tips when switching medical aids, or moving to a new medical aid plan:

1. When can you switch to a new medical aid or a medical aid plan within your existing one, and what is required to do so?

Members of open medical schemes can switch to a new medical scheme at any time, though they may be subject to waiting periods on the new medical scheme. These waiting periods will be based on the period they have belonged to a medical scheme and their answers to underwriting questions.

Members can downgrade their plan within their existing medical scheme at any time. They can upgrade their plan choice annually on January 1. Plan upgrades at any other time during the year are not allowed, to protect members against the costs of selective upgrades.

Whether a member is considering an alternative medical scheme or a change of plan in their current scheme, it’s advisable to contact their financial adviser to advise them on their available options.

2. What factors should you consider when switching to save on costs?

The most important consideration is the medical needs of the member and their family. Though a plan downgrade may save the member monthly contributions, the additional out-of-pocket expenses to continue to meet the medical needs of the family must also be considered.

Members should consider network options since these typically offer the same benefits, but within a defined network of health-care facilities and health-care professionals. Network options also offer a discounted contribution based on the network efficiencies.

Members who decide to downgrade their plan must be fully aware of the impact it will have on their future cover for health care. This may include lower levels of day-to-day health-care services, or lower levels of cover for major medical expenses such as cancer and medical emergencies. Members should make alternative provision for the financial impact this may have.

Financial advice is critical for this decision — it may be possible to maintain the same plan by allowing an accredited financial planner to reconsider the cost of the member’s financial planning portfolio, including life and disability insurance, and not just the health-care component of that.

3. What should you look for when first getting medical aid if you haven’t had cover before?

Don’t just choose the cheapest cover. The considerations are the same as for an existing member who is considering a change in plan, such as medical needs, network options, and provision for benefits not available on the plan they can afford. 

4. What factors should you look for in a new plan within the same medical aid company? For example, if you haven’t been to the GP in a year and are in good health, what should you consider?

Members who move to a plan with lower levels of cover for day-to-day health-care services on the basis of their current health must be aware of the impact the move may have on their cover for major medical expenses, including cancer. Though they may save in contributions, they may compromise themselves when it comes to the cover for expensive medical events not really related to their current levels of health.

5. What are the biggest things that leak funds from your medical aid, and how can you best avoid them?

The items that can deplete your medical savings account, or lead to avoidable co-payments and out-of-pocket expenses, include visiting doctors, pharmacies and health-care professionals outside the network covered by the member’s plan; claiming for over-the-counter medicines; and doctors that charge above the rate covered by the medical scheme.

Discovery Health provides members of Discovery Health Medical Scheme and participating medical schemes they administer with digital services to locate health-care providers whose services are covered in full by their plan.

Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised financial services provider and administrator of Discovery Health Medical Scheme, which is the largest open medical scheme in SA and a non-profit, separate entity.

This article was paid for by Discovery Health.