What do you look for when choosing a health care scheme? This is a question that many consumers struggle with.

Being part of a health care program is expensive, so consumers don’t like to pay, especially if they and their families never get sick.

They only realize the value when someone actually gets sick, as many have during the pandemic, or when a family member is injured in an accident. Choosing a health care plan is not something you do right away, and you should approach this important decision carefully.

You need to make sure you can afford the membership and that you get the coverage you need, so keep the following tips in mind.

Check your budget

This can be an expensive exercise and so you need to look at your budget to see how much you can afford per month.

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What do you need from a health care program?

Answering the following questions will help determine what you need from a health care program: Are you single or do you have a family that needs health insurance? How old are you and your wife?

Do you have children and how old are they?

Do your families have hereditary diseases?

Does one of you suffer from a chronic disease that requires ongoing treatment, or is your family healthy and living a healthy lifestyle?

Does your child get sick every winter?

Ask people you know about their health insurance

Ask family, friends and your GP if they are happy with your care schemes.

Ask if their claims are paid quickly, or do they have to spend days on the phone trying to deal with an unpaid doctor’s bill?

A good health care scheme pays on time and has good guidelines to help you understand what it pays for.

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Ask an expert

Once you’ve decided to join a health care scheme, make an appointment with a health care scheme broker as it’s important to speak to someone who isn’t trying to sell you membership of one particular scheme, but who can help you choose the right one for your needs .

Check the reserves of health care schemes

Health care schemes must, by law, have at least 25% of members’ contributions in reserve and must invest them to ensure they have the funds to pay claims.

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What does the health care scheme offer?

You should be wary of health care schemes that make huge promises with lots of benefits, but when it comes to paying claims, offer very little with lots of exclusions.

Consider daily limits and the size of your savings account per year. For example, if you have a child who is often sick, your benefit could be exhausted by April if there is only a small amount in the savings account.

Also look at how much you will have to pay out of pocket compared to what the scheme will cover.

Consider the amount of hospital benefits and see if you will be restricted to certain hospitals, and if so, if one of those hospitals is near you. It is ideal to choose a fund that provides 200% of the fund rate for inpatient treatment.

If you have to get health care for a family of four, a health care scheme that pays out 600,000 rand per family per year won’t cost much, as many families have seen during Covid when whole families have to were admitted to the hospital.

Cancer treatment is also an important factor. How is cancer treatment determined and will the health care scheme pay for new treatment if someone in your family develops cancer?

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Health care schemes usually have two exclusions: an exclusion for less than a year if you are a new member, and exclusions that will last forever.

You should first check these exclusions and make sure you are satisfied with them before you join the health care program.

Wouldn’t a hospital plan be better?

Although hospital plans are often more affordable than membership of a health care scheme, you should remember that a hospital plan only pays out when you are admitted to hospital, subject to certain conditions.

The hospital plan only pays to cover loss of income, not direct medical expenses.

Out-of-pocket medical costs can far exceed the amount a hospital plan pays.

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Medical aid scheme or health insurance?

Your health care scheme pays for medical conditions according to the scheme’s rates, but health insurance, like all insurance products, will pay a fixed amount if something happens to you, rather than paying specific amounts for certain medical services.

Health insurance covers loss of income and unexpected expenses, but not direct medical expenses. Medical expenses can also far exceed these contingencies.

Health care schemes and health insurance providers are controlled and regulated by law and regulatory bodies.

Under the Medical Schemes Act, certain medical illnesses and emergencies, called Prescribed Minimum Benefits (PMB), must be fully covered by medical schemes regardless of the type of plan you use, but health insurance does not have this requirement.

There are more than 300 PMBs that cover emergencies, most cancers and 27 chronic conditions such as asthma and diabetes. Health insurance benefits are not guaranteed by law.

Health care schemes also offer open enrollment and community rating. Anyone can join the scheme of their choice and cannot be turned away and all members pay the same monthly premium for the same benefits under the scheme plan option.

On the other hand, in the case of health insurance, your premiums are determined by the state of your health. If you have a pre-existing condition, you will pay more for your health insurance and may even be denied coverage if you are too high of a risk.

Health schemes operate in the same way as mutuals for the benefit of members, not for profit, which are governed by a board of trustees. Health insurance is provided by long-term insurers owned by shareholders who expect to make a profit.

Protection of consumer rights

Health insurance is treated as long-term insurance and is therefore regulated by the Long-Term Insurance Act, which is enforced by the Financial Services Board.

Medical care is governed by the Medical Schemes Act, which is enforced by the Medical Schemes Council. This means that your consumer rights regarding health care and health insurance are different.

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