Questions a Medical Aid Broker may ask you..

When you want to investigate joining a medical aid, here are some questions that a good broker should ask of you.

Are you planning to start a family?
Do you or anyone in your family currently have any chronic conditions? If yes, which chronic conditions?
Do you or anyone in your family currently have cancer?
Do you or anyone in your family need specialized expensive medicine?
Do you or anyone in your family currently use medical equipment or might need to in the near future? Examples: hearing aids, wheelchairs, oxygen.
How many dependants do you have that you would like to add to your medical scheme?
If you have children, how many children will be added to your medical scheme?
How much are you willing to spend on your medical scheme a month?
Are you comfortable with ordering your medicine online and having it delivered to you, instead of collecting it from a pharmacy?
On average, how many times do you and your dependants visit healthcare professionals in a month?
Do you need full or partial optical and dental benefits?
Do you want a top-of-the-range plan that provides the most extensive hospital cover for admissions, including access to a private ward, chronic medicine, and day-to-day benefits?
Do you want a plan that covers unlimited day-to-day benefits, comprehensive hospital cover for admissions, and chronic medicine?
Do you want to be able to go to any hospital for planned admissions?
Are you willing to use a hospital network for planned procedures to reduce your monthly contributions?
Do you want the certainty of comprehensive hospital and chronic medicine cover but don’t need a Medical Savings Account as you carried over enough funds from last year, but would prefer an unlimited Above Threshold Benefit?
Do you want cost-effective hospital cover for admissions, essential chronic medicine cover, limited day-to-day cover, and a limited Above Threshold Benefit just in case?
Are you looking for the most cost-effective hospital cover for admissions, essential chronic medicine cover, and limited day-to-day cover?
Do you need affordable medical cover and are you willing to use a network of providers both for hospital admissions and day-to-day medical care?
Do you want a value-for-money hospital plan that provides unlimited hospital cover and essential cover for chronic medicine?
Are you an active person with special needs for sports-related benefits?

Answers to these questions allow the broker to understand your and your family’s current health situation and past medical history, so you can find a plan that best suits your needs and budget.

What Are the Questions You Need to Ask?

What Should I Consider When Comparing Medical Aid Plans?

1. Level of Cover

Does the plan offer comprehensive benefits, including in-hospital and day-to-day benefits, or is it limited to hospital care only? Some plans may also provide specific benefits for chronic diseases, dental care, and optometry.

Comprehensive medical aid plans provide broad benefits that include hospital expenses and day-to-day medical costs. This includes visits to general practitioners, specialists, dental care, and prescription medications. Hospital plans typically cover only in-hospital treatment, leaving out many routine healthcare expenses.

Comprehensive plans often come with higher benefit limits for various medical services, so you have access to necessary treatments without worrying about exceeding benefit limits. This is particularly important for families who may face unexpected health issues or require ongoing treatments, such as chronic disease management.

2.What Can I Afford?

Your budget is a critical consideration.
Choose the best most affordable medical aid plan that is within your price range to ensure good benefits without straining your finances.

A general guideline is to allocate up to 10% of your monthly income to medical aid.
Note that a late joiner penalty may be imposed on individuals who join medical aid after age 35, the extent of it depending upon your prior membership.
We will help you identify if you are at risk of ths penalty.

Use us to get quotes from various medical aids.
Compare them and select those that seem reasonable. Then look more closely at what benefits you are getting for that cost.
Cheap is not necessarily the best!

A hospital plan is your foundation plan.
It will address your greatest risk of high medical costs.
You can then self-pay day-to-day costs or look to a plan with a savings account – if you can afford it.
But a hospital plan is vital.

How Can I Save Money on Medical Aid Premiums?

Choose a Network Plan:
They often have lower premiums. Network providr pans pay costs id full as they have negotiated rates with medical aids who pass those savings onto you. That can save you money.
Increase Your Co-Payments: Higher co-payments for services can reduce your monthly premium.

Take Advantage of Preventive Care Benefits: Like preventative screenings and health assessments offered by your plan.
Early illness detection can save significant costs and improve your health outcomes. Get your annual check-up, immunizations, and screenings to detect or prevent serious diseases and stay healthy and avoid costly treatments.
Make Use of Virtual Care (Telehealth): Doctor visits when your GP isn't available. Virtual visits can be a quick, convenient, and cost-effective option.
Annual Review: Regularly review your medical aid plan to make sure it continues to meet your changing healthcare needs.
A different plan may be far more attractive.
Use a Professional Medical Aid Broker like Us:
Because we understand medical aid “fine-print” and can help you find the best deal to suit your needs and wants.

What Should I Be Aware Of?

Co-Payments and Deductibles
Understand any additional costs you may need to self-pay for specific treatments or procedures. Most plans require procedure and other co-payments. Be aware of any that may affect you.

Buy Top-Up/Gap Health Insurance
A comprehensive health insurance plan will pay in-hospital medical aid claim shortfalls and procedure co-payments you may have from your medical aid.

If you join a good Gap/Top up and you can consider joining a more affordable, lower benefit hospital plan as the insurance should pay the claim shortfalls.

Effective Strategies to Reduce Out-Of-Pocket Medical Expenses

Try using generic medications instead of branded ones, as they are typically cheaper and covered by your medical aid.

What Are the Plan’s Network Benefits, and Are They Easily Accessible?
Does the medical aid plan allow you to choose your own service providers, or are you limited to a specific network?
Having the ability to use your preferred healthcare professionals may be an important factor for you.

Would you use network hospitals as they can offer guaranteed payments by the medical aid at a lower premium?
Investigate network benefits and if you can easily use the providers they have.
Check if your preferred doctors, specialists, and hospitals are part of the plan's network.

What Are the Exclusions?

Be aware and fully understand any exclusions the plan may have, especially if you have pre-existing medical conditions.
This information is vital when choosing a medical aid.

Some examples of general exclusions are:

Compensation for pain and suffering, loss of income, funeral expenses, or any other claim for damages.
Costs arising from wilful, self-inflicted injury, or excessive use of intoxicating substances or drugs.
Cosmetic procedures, obesity treatment, infertility, and any complications.
Recuperative or convalescent holidays.
Expenses incurred outside South Africa (unless there is a special benefit provided).
Conditions subject to waiting periods when the member joined the scheme.
Purchase of patent medicines, proprietary preparations, toiletries, sunglasses, beauty preparations, tonics, slimming preparations, appetite suppressants, household and biochemical remedies.
Claims not submitted within a stipulated period after the month in which the service was rendered.
Expenses for which a third party is liable, like occupational injuries, motor vehicle accidents, or medical services covered by other insurance.
Examinations for insurance, school camps, visa, employment, or any similar purpose.
Accommodation in convalescent or old age homes.
Costs associated with vocational guidance, marriage guidance, school therapy, or remedial education.
Sleep therapy and hypnotherapy.
Costs associated with active participation in wars, riots, or civil disobedience.

Exclusions for Pre-Existing Conditions
Pre-existing conditions can be excluded from cover for the first 12 months when joining a new scheme.
Acute or chronic diseases, physiological states like pregnancy and menopause are considered pre-existing.

Other Exclusions like:
Operations, medicines, treatments, and procedures for gender alteration or re-alignment for personal reasons.
Rehabilitation, except for PMBs.
Optical items like repairs to frames/lenses, contact lens solution, sunglasses, lens tints.

What Waiting Periods Apply?

The scheme needs to underwrite your application before confirming if any waiting periods will be imposed.
Based on your answers to the medical questions, they can add waiting periods for specific conditions of up to 1 year.

If you have never been a member of a medical aid or have a break of more than 90 days in membership, you will get a 3-month waiting period and could get a 12-month condition-specific waiting period.
No PMB benefits as well.

If you were a member of a medical aid for less than 2 years and are applying for membership within 90 days of leaving a scheme, you may get a 12-month condition-specific waiting period.
You will have PMB cover.

If you have been a medical aid member for 2 years or more and are applying for a new medical aid within 90 days of ending that previous membership, you will get a 3-month waiting period, no condition specific waiting period.
You will have PMB benefits.

You may also get a 3-month waiting period where you voluntarily change schemes.
If you are forced to change medical aid because a company scheme is switched or retire and cannot remain on the medical aid, no waiting periods will apply.

What are the Benefit Limits?

Investigate capitation on benefits for specific procedures or treatments. Understanding these limits can help you avoid situations where you might be underinsured.

How Do I Choose the Right Medical Aid Plan?

Medical aid plans typically fall into 3 categories:
hospital plans,
hospital and day-to-day savings plans,
traditional comprehensive plans with set benefits.
Understanding the differences between these options lets you select the best plan for you and your family.
Most popular plans are hospital and savings, however, a comprehensive plan may be more cost-effective in the long run, despite higher premiums, when considering possible out-of-pocket expenses and the benefits that are offered.

How do I Join a Medical Aid?

Making an informed choice when selecting a medical aid plan is crucial.

If you need help understanding your options or have questions about specific plans, contact me for expert guidance.

What Is the Claims Process?

Understand the scheme’s claims process, including how to submit claims, the turnaround time for payments, and any requirements for pre-authorisation or referrals.
Appeal denied claims as sometimes errors can be rectified.

What Are Common Mistakes Made When Choosing a Medical Aid?

Ignoring exclusions, which can result in unexpected costs.
Overlooking network restrictions and finding you cannot use any of the listed providers.
Choosing a plan based on premiums, without considering the plan's benefits and limits.
This can leave you underinsured when you need coverage the most.
Not reviewing the plan annually. Medical aid plans and your health needs can change over time.
Regular reviews ensure that your plan still meets your needs at the best possible price.
Failing to consider family needs, especially if you have dependents.
What might be sufficient for a single individual might not cover the needs of a growing family.

Talk to me .... I am here to help you - at no charge!
Send me your questions and concerns. I'll answer them for you.

083 655 2164

You must consult the schemes/company product brochures and rules for comprehensive benefit descriptions.

We will offer you the best help at no cost!

Medical aid pays healthcare costs.
What if a disability stops your income?

YOUR TRUSTED, QUALIFIED ADVISOR:
Peter Pyburn - Authorised Financial Services Provider, fully licensed to render financial services since 1991. Death and Disability Planning; Retirement Planning; Investment Planning; Healthcare and Estate Planning.

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Last update: January 18, 2025