There’s no need to navigate your medical aid alone

Stethoscope and laptop

There’s no denying that medical aid membership is expensive and, with medical inflation outstripping consumer inflation by around 3% to 4% year-on-year, it’s likely that your medical aid premiums will consume a bigger and bigger proportion of your household consumption over time. However, what many open medical scheme members don’t realise (think Discovery, Fedhealth, and Momentum Health) is that a portion of their monthly premium is paid by the scheme to the broker on record in the form of commission. That means that the broker who introduced you to the scheme will continue to earn commission paid from your monthly contribution, with this commission currently legislated at R118.18 per month (excluding VAT) or up to 3% of contributions (excluding VAT), whichever is the lower. So, if you’re a member of an open medical scheme and you’re not receiving advice and service from your healthcare advisor, ask yourself why – because you’re paying a fee for it.

The need for advice and service

The primary function of your healthcare advisor or broker is to ensure that you and your loved ones are on the most appropriate plan option for your needs and that, as a family, you are receiving full value for the private healthcare you’re paying for. Simply put, if you’re not on the right plan option and/or are not utilising your benefits properly, you could end up paying for medical care out of your own pocket which, in turn, could detrimentally affect other areas of your financial portfolio. In return for his/her monthly commission, your healthcare advisor should keep in regular contact with you to ensure that you are making optimal use of your medical aid and not incurring out-of-pocket costs unnecessarily. Further, if you’re unsure how to use your network option properly, how to pre-authorise your hospital admission, or how to claim from your gap cover provider, you could end up with huge medical bills that you hadn’t accounted for. As such, your healthcare broker has a critical role to play in the utilising of your medical aid and reducing your out-of-pocket expenditure.

The medical aid industry

The medical aid industry is a highly complex one and is notoriously difficult to navigate alone, which is why the Council for Medical Schemes provides for the remuneration of registered medical aid brokers whose role is to provide ongoing advice and service to their clients. With 17 registered open medical schemes to choose from and literally hundreds of options, one of a healthcare advisor’s jobs is to distill the available information, analyse the client’s specific needs, and make recommendations for appropriate healthcare cover. The selection process is not always easy as no two medical aids are the same, and comparing apples with apples is almost impossible. To demonstrate the complexities inherent in this sector, Discovery Health offers 7 plan categories with a total of 25 plan options to choose from, while Momentum offers 35 plan options across 6 different scheme categories – excluding the wide range of gap cover options available to medical aid members.

The role of your healthcare advisor

Over and above helping you choose the best plan option for your needs – something that should be re-assessed every year (or during the year if circumstances require), your healthcare advisor should be readily accessible to help you navigate your medical aid and gap cover in the following ways:

  • Registering new dependants on your medical aid (for example, on the birth or adoption of a child), or de-registering dependants (such as in the case of death or where a dependant no longer qualifies as such);
  • Assisting with submitting medical aid claims and ensuring timeous refunds;
  • Helping you to register on the disease management programmes offered by the scheme such as oncology, asthma or diabetes programmes;
  • Advising on the network of hospital and/or service providers relevant to your plan option;
  • Providing guidance on how to claim from Prescribed Minimum Benefits and/or whether you claim qualifies as a PMB;
  • Assisting you with registering on the chronic medication programme including advice on which medicines are listed on the formulary;
  • Communicating rules and guidelines on how to obtain your medication and/or treatment for your condition;
  • Providing medical aid advice if you intend travelling overseas and generating travel insurance certificates for these purposes;
  • Communicating proactively regarding any benefit or limit changes made by the medical aid;
  • Generating tax certificates for the purposes of SARS e-filing;
  • Providing guidance and education of waiting periods, later joiner penalties and any condition-specific waiting periods that you may be faced with;
  • Assisting with obtaining hospital pre-authorisation for any planned in-hospital procedures;
  • Contacting the medical scheme on your behalf to assist with query resolution and/or escalation;
  • Providing advice on appropriate gap cover to help fund the shortfall between the amount charged by service providers in hospital and the medical aid tariff;
  • Assisting with the submission of gap cover claims;
  • Facilitating the payment of any late or overdue contributions;
  • Educating the client on any loyalty programmes attached to the medical aid and how best to optimise the benefits;
  • Assisting with the replacement of lost or stolen medical aid cards.

As is evident from the above that your medical aid advisor has a pivotal role to play in helping you navigate and manage your healthcare. Further, as one’s personal health and circumstances can change rapidly, the advice and service should be both proactive and ongoing.

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