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Here are 10 Tips to help you choose a medical aid plan.

What you should be aware of before you choose a medical aid plan.

How to select the right medical plan, that comfortably suits your needs and pocket.
Which healthcare plan should you choose and join?
Tips on what should you look for when looking for healthcare funding plans?

If you can afford a premium of more than R10,000 per month, then you can have a medical aid that pays everything!
If you cannot, you need to know what healthcare plans are available and what you can do to choose the best plan for your budget.


10 tips on choosing medical aid1. Decide on what cover you need.

The greater the benefits you want - the higher the premium you pay!
It is as simple as that!
So your first step is to find a plan that meets your needs and wants.

Please see my page on the Different Types of Medical Aid Plans.

It shows you what is on offer from Traditional, New Generation with savings, hospital only and network plans. It will guide you on what various plans can offer you.

A plan without the "bells and whistles" (say a hospital only benefit plan), can save you considerable money! You need catastrophic cover - big accident, illness or disease - insurance. Most people can take care of day-to-day, out of hospital costs themselves.

So, you decide if you want a COMPREHENSIVE PLAN (offers in and out of hospital benefits) OR a HOSPITAL ONLY plan, (where you pay all out of hospital costs).

Hospital plans are far more affordable than full medical cover and do provide chronic medicine benefits as well.

One plan even pays essential dentistry costs taking care of emergencies like fillings and extractions!

However, if you have high day-to-day needs, you will need to consider joining a Comprehensive plan, as these will assist you in meeting your higher treatment-usage costs.

Medical schemes offer a variety of plans that differ in the rate that they pay in-hospital claims.
Please see How a Medical Scheme Pays Claims for a detailed explanation on how this works.

Plans paying at medical aid rates cost less than those that pay at private rates (2 or 3 times medical aid rates).
But, these "private rate plans" can still short pay in-hospital claims as private providers charge up to 5 times medical aid rates!

Your answer is to join a Top Up or Gap Insurance plan.

A separate insurance from a medical aid, it is designed to help pay any hospital-claim shortfall or procedure co-payment the medical aid charges.

If you do take a top up plan, you can look at joining a medical aid rate plan - with a cheaper premium - because the Top Up /Gap cover will make up any possible in-hospital claim shortfall.

The "saving" from the lower premium medical aid, should pay for the Top Up plan and still offer a lower, overall contribution!

And that, along with cover that pays up to 5 times medical aid rates in hospital, is unbeatable!



look at your health2. Look at your current healthcare needs, past treatments and costs.

As a start, you need to know what level of medical aid it is, that you will need to join. Consider your past hospital, specialist, GP, medicine, dental and optical costs, and you will have an idea of the extent of benefits your plan must give you.

If you seldom need medical treatment, unless you suffer from a major medical need, then all you need is a simple hospital-only benefit plan. You pay out of hospital costs yourself.

If not, you may need a plan with a savings fund to help with day-to-day expenses. If you frequently see a GP, or you need expensive, on-going chronic care, then you may need to consider a fully comprehensive plan.

Also consider any hereditary conditions, like glaucoma and other incidences of dread disease in your family. You may need full, comprehensive medical cover rather than a hospital plan.
If you have an eye or dental problems, it is to best choose a plan that offers these as benefits.

Some questions you should ask .....

  • How much did you spend on day-to-day healthcare costs during the past year?
  • Where did you spend that money? GP visits – Hospital – Dentistry - Medication?
  • Which costs will not happen again (like childbirth)? And which are likely happen again (like flu)?
  • What if you do if you use all your day-to-day savings during the year? Can you afford to pay further bills yourself or will you need medical aid cover?
  • Do you need chronic medicines? Or, maybe consider a cheaper plan and pay for some medicines yourself - a lower premium may save a lot more than the medicine cost?
  • Can you pay for doctor, chemist and dentist visits yourself? If yes, choose an in-hospital plan. (Our biggest costs are generally private hospital and dental treatments.
    And we have a plan that will pay both these without using any of your savings!)
  • Can you use network providers? If so, you can get substantially discounted premiums!
  • You may feel you don't need medical aid but, not having at least hospital cover, is like driving a car without a spare tyre. You will need it at some unexpected time and if you don't have it you can be in serious trouble!

    A 20-year old who hasn’t seen a doctor since birth needs something quite different from the 50-year old with high blood pressure and diabetes!



    how much can you afford3. How much can you afford?

    Top-of-the-range medical aid will be very expensive!
    If you only earn R6,000 pm, then you cannot spend R2,000 of it on medical aid. Simple!

    There are plans that allow low-income earners to access private healthcare.

    These plans offer no overall limit hospitalisation and mostly unlimited primary day-to-day care. Essentially, they give life-threatening (heart attack, car accident) and life-sustaining (kidney, cancer illness) cover - all for a low contribution.

    They are ideal for low-income families who need GP cover and pensions on a fixed monthly income.

    An expensive medical aid will have better benefits than a low cost one. But it is possible to find plans with good hospital cover and lower day-to-day saving funds - in turn, dropping your total contribution!

    Here is an excellent scheme offering you the maximum flexibility in managing savings accounts and helping to reduce your overall premium!

    The "trade-off" is that if you run out of savings, you pay day-to-day costs for the rest of that year. However, in many cases, there is a significant cost saving for you, when investigating these plans. Some plans offer a safety net - in the form of unlimited network GP consults - if you do run out of funds.

    Investigate which scheme will give you the best rates for your partner and young adult children.
    Some plans cover financially dependent children to age 27!

    Please note that hospital insurance plans - that pay you per day you spend in-hospital - very seldom cover even a fraction of the medical costs!




    afford healthcare plan4. Premium increases.

    The cost of medical care is incredible. Every year we read about the "hurt" medical scheme members receive when new premium increases are announced.

    Medical inflation is around 12%. That, added to running cost of schemes, has resulted in increases way above the CPI rate and salary increases!
    Unfortunately, there is little we can do about this, except try to reduce the cost of your medical aid.

    It is important to understand how a medical scheme's increases relate to overall inflation and other schemes. Excessive and continuous annual increases indicate serious flaws exist in that medical scheme!
    Schemes in 2020 have around a 10% increase in premium!

    But, one scheme boasts a 5,5% increase!
    Please take a look ...



    5. Check a scheme's payment record.

    If you decide on a scheme, phone your GP, or the nearest private hospital, and ask them whether they have experienced problems with claim pay-outs from that particular scheme.

    Check on the Internet for administrative and service concerns members may have posted. (Hellopeter or My Broadband etc. You certainly don't want to join a medical aid that has a dreadful servicing record!

    Investigate the scheme's solvency ratio.
    Investigate the scheme's solvency ratio as the last thing you need is to have paid your premiums. only find out that the scheme has gone insolvent while you were in a hospital having kidney stones removed!

    The Council of Medical Schemes is tasked with checking schemes comply with solvency requirements.
    Schemes should have at least 25% of members' annual contributions in reserve.

    We can help you avoid joining a scheme that is not financially sound!

    A scheme with large membership is more secure. If they lose 1,000 members, the effect on their solvency will not be as great as a small scheme that loses the same number of members.

    Let us help you find that scheme!



    overall annual limits6. Check the overall in-hospital limits.

    It is impossible to know how much hospitalisation will cost. There are so many factors that are involved, let alone the ever-increasing cost of care, that you cannot make a guess.

    It is therefore vital you consider plans with no overall in-hospital limits.

    If a scheme limits hospitalisation to R1 mil per family per year, what would happen if you all were in the same accident and had to spend a week in intensive care?

    In 2018 a day in intensive care required R 27,000. A family of four would require R 108,000 PER DAY or R 756,000 over a week.
    And that is only the cost of a general ward, no specialist or treatment costs!

    A no overall annual limit, in-hospital benefit is the minimum cover you should consider.

    No overall annual limit does not mean that every cost in hospital is paid. Benefits have sub-limits - as listed in the plan rules - and these can limit certain claims and lead to co-payments for you.

    An example is cancer cover. A plan may say it is unlimited, but they levy a co-payment after a pre-defined amount is paid out.

    Check the HIV cover as in South Africa, this is important.
    What will the scheme pay should you become HIV-positive and, maybe require a lengthy hospital stay, or chronic medication?



    7. How to Choose the Medical Aid Best plan.

    Here is a guide to selecting the type of plan that may suit you.


    best medical aid planIn your 20's: consider a hospital only benefit plan.

    Young and healthy, you may have little need for doctor visits and medicines.

    BUT, we live in a violent country and you do need cover for emergencies. catastrophic events (big accident, illness or disease) and maternity. You do not want to rely on your family to pay medical costs!

    You are laying the foundation for your future health, so ensure you get preventative care benefits with your plan.



    family medical aid planIn your 30’s: look at an affordable cover for a family.

    With children, you need a more comprehensive plan - hospital, GP, chemist, dentist and optical benefits.
    But, these are expensive plans, so consider a cheaper option that uses network providers.

    Prevention is better than cure, so you need regular dental, cholesterol, glucose and blood pressure tests.

    Pregnancy is expensive! Your plan must cover you throughout pregnancy and birth. Consider a more comprehensive option before you plan to start a family.
    Medical schemes will not cover pregnancy if you have already conceived.


    mature medical aid planIn your 40s, 50's and older: the more cover the better.

    You need more comprehensive benefits.
    Heart disease, cancer, osteoporosis and dread diseases develop during these years, so you need a plan which pays for chronic medication.

    If you are prepared to use providers listed with a scheme, look at a network provider plan.

    These schemes are good at controlling costs and then passing savings on to the member through lower rates.

    You save on your monthly premiums by making use of healthcare providers and hospitals within a specific network.
    You may have a concern, because you can only use certain healthcare providers. However, if most of the listed network providers are easily accessible, it’s a perfect match.

    Many network options offer full cover for in-hospital treatments, including specialists, and day-to-day benefits, giving you a more comprehensive benefit than you might expect.

    INGWE Network Medical Aid - This plan offers an ANY hospital option as well!

    KEYCARE Network Medical Aid - the most popular plan in South Africa.


    You may also feel you do not need expensive day-to-day benefits.
    If so, consider a hospital only benefit plan.

    Hospital plans provide the same comprehensive in-hospital cover as most other, more traditional medical aid benefit options.

    The main difference is that a hospital plan may not cover out-of-hospital benefits like GP visits and optometry.
    But, if you are a healthy person who visits the doctor or dentist once a year, that may not be such a problem.

    Because a hospital plan is much more affordable than a comprehensive medical aid, you can use that saving in contribution, to pay for your out of hospital expenses. It may still be cheaper, over a year than joining a comprehensive medical aid.

    Work out what you spend - out of hospital over a year - add 15% as a "bad luck" buffer and compare that amount, to the premium you save by joining a hospital only plan.
    I bet it will surprise you!

    A good medical aid blog



    gap and top up plan8. Gap Cover Must be Your Friend!

    Gap/Top Up cover is the most affordable way to supercharge your current medical aid option - at far less cost than upgrading it!

    Gap cover is designed to do just that... cover shortfalls between what your in-hospital healthcare providers charge and what your medical aid pays.

    And schemes are increasingly adding procedure co-payments, which a Top Up pays as well.

    Premiums for a good Top Up are around R 350 pm and you can buy from any company you want.
    Top up insurance is a totally separate product from any medical scheme.


    Some procedures not fully covered by medical aids.
    2020 shortfalls paid by Gap Cover.
    Natural Childbirth
    R 19 250
    Caesarean Section Childbirth
    R 29 645
    Tonsillectomy
    R 8,391
    Hernia Repair
    R 35 622
    Breast Cancer Surgery
    R 54 158
    Hip Replacement Surgery
    R 81 730
    Spinal Surgery
    R 147 782
    Cancer Treatment
    R 120 240
    Heart Surgery
    R 165 654


    For more detail on this very valuable addition to your medical aid, please read The Valuable Benefits of Top Up/Gap cover Insurance.



    9. Know the Plan's Exclusions.

    Best you know before you join a medical aid just what is NOT paid.

    When you join a medical scheme, your application is underwritten the scheme and may add waiting periods. Anything from 3-months for everything, up to 12-months for specific conditions.

    If you are already pregnant, the scheme will exclude your pregnancy for a year - but will cover your child from birth. You must be a member at that time.

    Lower cost plans have more exclusions. Joint replacements, specialised dentistry and so on are not covered.

    So, be aware of these possible exclusions before joining by making a point of reading the plan rules!



    10. Medical aid brokers offer free advice as to the best schemes and options for your requirements, based on your available budget.

    When you join a broker-recommended scheme, you don’t pay a cent! The medical scheme pays a fixed monthly commission, provided the broker is contracted to the scheme.

    If you do go direct, you pay the same premium.

    So, why not use our skill and experience in this industry. For sure, most people will need help!



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    Last update: December 7, 2019

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