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Best Advice and Tips on what to do for your Medical Aid.

What a healthcare adviser does for medical aid.


Here are the Best Tips on what to do for your Medical Aid.
Do you downgrade or join a hospital plan?

The cost of healthcare is huge! Medical inflation is way above normal consumer inflation and with the effects of the pandemic drastically affecting our incomes, most medical aid members have little option but to investigate alternative healthcare plans and ways to afford healthcare.

The greatest risk we face is not having medical aid today – so do not cancel your plan!

If you are considering stopping your medical plan and saving that premium to self-fund your medical cover … THINK AGAIN!!!

These ideas may help you prevent having to terminate your valuable cover.

And if you are not yet a member – BEST YOU JOIN A PLAN TODAY!

Unfortunately, medical aid is a necessary evil.

medical aid adviceThe Covid-19 pandemic has made us realise just how important it is to be a member of some sort of medical insurance plan – whether that is a simple hospital only or fully comprehensive plan.

Living in South Africa, you have no choice but to have some sort of healthcare. The state medical system is not an option – unless you have no option but to use it.

Life-saving treatment in private care will cost far more than your monthly medical aid premium!
You are not bullet-proof. Don’t think you are never going to face high medical expenses. Accidents or illness can and does happen – to anyone of any age!

Join medical aid NOW. It’s the finest safety net you can get for you and your family.

Anyone needing emergency medical attention or admission to hospital – say from a car accident or Covid-19 - who has no medical aid has a HUGE problem! An ambulance will transport you to the closest suitable trauma facility and this needs to be private care.

But if you have no medical aid, they will stabilise you then transfer you to a state facility. Not the best situation for anyone!

They may also not admit you without a substantial cash deposit being paid – before any treatment is given!
This can be absolutely devastating to your financial circumstances.

Private healthcare is very expensive and with no “medical insurance” plan, self-funding private hospitalisation, (even for a single operation) will quickly exhaust your savings.

Even if you are unconscious and it has been established that you belong to a medical aid, you will be taken to a private hospital. Just think what will happen if you are not a healthcare member!

Please remember that state care still requires payment of fees, depending on what they believe you can afford!
You still land up paying for treatment, but in an overcrowded and understaffed hospital with little prospect of getting the care you may desperately need. Again, not ideal!

A simple procedure like the removal of wisdom teeth (with a few hours in hospital) can cost upwards of R13 000!

The potential costs of treating COVID-19.

covid19Suffering from COVID-19 greatly increases the risk of complications with co-morbidities, or the coexistence of two or more diseases or disorders you may have – and not know that you do!

Without medical aid, all your medical expenses, especially those at a private facility, will be for your own account. And this at a time where you’re at risk of falling seriously ill.

However, COVID-19 is classified as a Prescribed Minimum Benefit (PMB), so a medical scheme has to cover costs related to your diagnosis, treatment and care (consultations, medication and hospitalisation).

A 2-week stay in a general ward can cost around R99 000.
But what if you need ICU care for say, 14 days? That can cost about R392 000!

Forced to use a state facility and you risk overcrowded wards, a shortage of staff, equipment, vital oxygen and ventilators.
Do you really want to take that chance!

During the pandemic, large numbers of patients have been avoiding necessary hospital visits, fearing catching the virus. This delayed treatment can only cause medical complications and fatalities, unrelated to COVID-19. And in the future, these patients will have to return to the hospital system, further stressing the healthcare system.

There is an increased risk of you not getting good private care in the future, especially as the number of good specialists and providers in South Africa is rapidly diminishing. You will pay – and pay a lot – for the best care in the near future!

Premiums always increase way above the rate of inflation. It’s a classic “supply and demand” price!

Joining a medical aid will protect you and your family from having to pay high, unexpected medical costs yourself.
It ensures that you can get the best treatment quickly and that is vital for any recovery!

You should, at least, join an in-Hospital only benefit plan to cover your greatest threat of high medical costs at a very affordable premium.

What you should do for a medical aid.

Terminating your medical aid is the worst decision you can take.
The best idea is to move to a lower, more affordable plan. or “buying-down”.

So, how best do you “buy down” a medical aid.

The greatest risk of high medical costs we face is with private hospitalisation and dental care and your plan must have the finest of these 2 benefits.

Medical aids offer 3 main areas of cover: in hospital, day-to-day and chronic illness benefits. That said, joining an expensive medial aid plan that has a day-to-day savings account for your day-to-day out or out of hospital expenses, may not necessarily equal better benefits!

We join a medical aid to ensure peace of mind and access to funds for the “big ticket” private healthcare costs.
Hospitalisation costs may run into hundreds of thousands or even millions of Rand.
Always make sure that you have sufficient risk (i.e. hospital and related costs) cover in place. Day-to-day expenses can be managed separately on an as-and-when basis.

A period in a hospital can cost a fortune, so we need - at least - a plan that will cover that risk.

Join a Hospital only benefit plan.

Most medical aids offer these plans.
Here we are ONLY talking to medical aid in-hospital benefit plans. Not hospital plans as these are insurance products, not bound by the same rules medical schemes have to meet. They pay fixed cash benefits and can be extremely restrictive when claiming - very unlikely to meet more than a small fraction of your actual costs.

Join an in-hospital only medical plan because, claims are determined according to the actual healthcare expenses you face and not on a pre-agreed, daily cash sum which can never accurately protect you from unknown costs!
A far more secure form of healthcare cover!

Please see Is a Hospital Cash Plan (not a medical scheme hospital plan) worth it?

Medical scheme in-hospital only plans cost less because they only pay for costs related to in-hospital treatment, including surgery, ward fees and/or specialist fees.

You pay all your day-to-day costs like GP consultations, physiotherapist, medicines and glasses on an as-and-when basis.
This is not too great a risk, as we have never heard of a member going bankrupt over a chemist bill. But a family spending 2 weeks in intensive care … well, that is another story altogether!

What does a hospital plan cover?

hospital plan benefits

A Hospital only benefit plan covers you from admission to discharge in hospital.

It pays accounts that are related to your treatments like theatre, X-rays, medication, blood tests, blood transfusions, etc.., and these are usually covered in full as hospitals charge what medical aids pay.

However, private providers like doctors and specialists can charge what they like.
And these fees can be up to 5 times what a medical aid pays!

Different medical aid plans will pay at 100%, 200%, or even 300% of these fees – the higher the payment, the higher your premium!
Shortfalls are almost guaranteed to occur with these providers and you should seriously consider a Gap or Top Up plan which will pay any shortfall or procedure co-payment.

And if you do join a Gap plan, you can then consider joining a “lower” benefit hospital plan with a lower premium, safe in the knowledge that you will have cover. In some instances, the “saved” premium of the lower hospital plan will pay the Gap plan contribution!

It is important to note that these plans offer the same hospital benefits as most comprehensive plans, but without day-to-day benefits.
Whether you are on a hospital plan, or a more comprehensive medical aid benefit option with savings, your medical scheme should fund your qualifying hospital claims in the same way.

3 Excellent Hospital plans to consider.

genesis medical aid

1. Genesis starting from R 1,340 pm.


Genesis is a scheme that really understands the financial pressure that lockdown has brought to South Africans.
They understand the need for reducing medical aid costs and the advantages of joining an affordable hospital plan.
So, for the ninth consecutive year,they have the lowest average contribution increase of all open medical schemes in South Africa!
They posted a 4,9% average increase for 2021.

AND ESSENTIAL DENTISTRY COSTS ARE PAID BY THE SCHEME!

Yes, both your highest medical financial risks are met in one, very affordable plan!

In the most recent GTC Healthcare Consulting Medical Aid Survey, the Private Choice hospital plan received a 95% score and was rated as one of the best hospital plan benefit options in South Africa!

You have full choice when choosing your preferred hospital, doctor, or medical specialist and have unlimited in-hospital cover.
You are not forced to seek treatment in network hospitals, nor required to make use of network medical practitioners.

Hospital accounts, including treatment for PMBs, will usually be paid in full and in private hospitals, the charges of attending doctors/specialists and other healthcare service providers, even for PMBs, will be reimbursed at 100% or 200% of the Scheme Tariff, depending which plan you join.

Genesis is able to boast of a very high claims paying ability putting giving you the security that your claims will be paid. They are very solvent!

If you can self-pay out of hospital costs then this is the scheme you need!

momentum medical aid

2. Momentum Health starting from R 1,706 pm


Offering comprehensive, no overall annual limit in-hospital and chronic illness cover on all plans, they give you the option of using any hospital or listed private hospitals.

They also offer discounted premiums depending upon your choice of any or listed hospitals or where you source any chronic medication you may require.
You have a choice of using any doctor or chemist, listed providers or state facilities with the greatest discounted premium (choose this option the plan if you have no chronic needs).

If you are concerned about self-funding day-to-day costs then this is your answer!!
This is the best scheme, because it offers you a safety net of money in case you suffer excessive out of hospital costs …

fedhealth medical aid

3.Fedhealth starting from R 1,788 pm with the option of using R 6,900 savings for day-to-day costs...


All Fedhealth plans are essentially unlimited hospital plans, but with the OPTION of using day-to-day savings if you really need them.
And only repaying those savings WHEN YOU SPEND THEM!

This is unique and revolutionary and gives you full control over how you use and pay for your medical aid!

Most medical aid savings accounts are really a compulsory loan, forcing you to pay for out of hospital benefits – even if you do not use them! They add an amount to your monthly premium – every month - to repay the loan. That is not right.

Fedhealth gives you full control over your savings. You only pay for what you use. So, when you do not use the savings, your premium remains lower, as you are not repaying a savings fund “loan”.

When you do spend your savings, the amount you use is repaid over the next 12-months – interest-free!
One-twelfth of what you spend is added to your premium till the “loan” is repaid.

And because these savings are not regulated as part of the medical aid, the amounts are higher than standard medical aid saving accounts.

If you don’t want the responsibility of controlling these savings and want plans that work like other schemes, (where savings are available and no added premium is done when spending them) Fedhealth offers identical plans, but with traditional saving accounts.
Premiums from R 2,088 with R 3,900 savings.

That’s not all … Fedhealth offer you lower premiums if you choose either of two discounts!

11% if you use listed hospitals (outside of an emergency) and 25% if you accept a R 12,500 fixed excess for planned procedures at a hospital of your choice.

Just look at what Fedhealth offer you...

Only Fedhealth pays for all of these benefits:

  • Unlimited network GP visits once you have reached a pre-determined claim amount!
  • 7-days take home from hospital medicines!
  • Unlimited Specialised radiology (MRI/CT scan) in and out of the hospital!
  • Unlimited 30-days post-hospitalisation treatment!
  • Female contraceptives!
  • You only pay for 3 children!
  • Financially dependent children pay child rates up to age 27!
  • Unlimited Trauma Casualty!
  • Certain post hospitalisation treatments for 30-days!
  • Upgrades any time of the year within 30 days of a life-changing event

2020 asked a lot from you. Now it’s your time to get answers.

ASK “WHY” other medical schemes make you take a more expensive option “just in case”, instead of letting you upgrade if something actually happens?
Then ask yourself why you haven’t switched to Fedhealth yet?

Thoughts on Day-to-day costs and how to pay for them.

Day-to-day (out of hospital) costs is the area where you can most actively control your medical aid premium.

A savings account housed within a medical aid is probably the most expensive way of saving! Although it is your money, you cannot control it, (EXCEPT FOR FEDHEALTH PLANS!) as the medical aid manages it for you.
And they charge administration fees for that!
So, you get less out, than what you pay in!

It is a compulsory loan you must pay – even if you seldom (if at all) use it.

If you don’t use out of hospital services frequently, it makes sense to consider insuring for your high-risk costs like hospitalisation and self-pay your day-to-day costs.

Where to save for your day-to-day medical expenses fund.

where to saveBecause these monies need to be easily available, you need to consider specific products like:

Many members are joining an in-hospital only benefit plan and self-paying their out of hospital costs.

(Obviously, if you have a high need for day-to-day services like GP’s and medicines, this is not an option).

This change will immediately save you considerable premiums!

As we have stated, high premiums or comprehensive medical aid plans do not always ensure better benefits.
Yes, some comprehensive plans do have added benefits like extended chronic illness conditions, biological drugs, unlimited cancer cover, etc..

However, if you have limited finances and have a choice of no medical aid at all or a hospital plan, the hospital plan is a “no-brainer” choice!

It will address your greatest risk and give you the finest peace of mind.

Other options to consider when downgrading a medical aid.>

other medical aid plansDowngrading your plan in order to reduce your premium can be a risk, especially if you and your family members suffer from ill health, have a family history of illness, or suffer from or may be at risk of a chronic illness.
A lower benefit plan may leave your family without adequate medical cover, particularly with an unforeseen medical event. You may have to self-fund for a number of incurred expenses.
Your expectations with a lower benefit (lower premium) plan, will have to reduce!

Sometimes, upgrading your plan may be a wise move. Although it does cost more, you will have greater peace of mind in uncertain times, knowing that your medical needs will be taken care of - especially when you have a growing or aging family.

Using linked providers.

Unfortunately, freedom of choice always comes at a price.
All medical aids offer plans that require you to use listed providers from hospitals to specialists doctors and medicines.
If you can use these providers, you get:

But, the trade-off is that you cannot choose who treats you.
And that your closest provider may not be convenient for you.

Income-related plans.

These plans require the use of linked hospitals and other providers and the premiums are based upon your income level.
They are designed to give low-income earners access to private healthcare.

However, because they have lower premiums, they have a number of restrictions - like no specialised dentistry or joint replacement benefits. A number of them also require the use of state hospitals, so you need to fully understand how they work.

You need to consult an experienced and licenced Healthcare Adviser to ensure you get the very best out of your cover.
We can advise on a plan that suits your needs and budget. We do not all have the same requirements, so talk to us!

We are here to help you, often at no cost, every step of the way!

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Last update: April 6, 2021

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