Medical Insurance

FEDHEALTH: With great benefits like unlimited visits at nominated Network Family Practitioners (FPs), unlimited private hospitalisation at all private hospitals and a basic dentistry benefit covered from Risk, the Maxima Saver option is ideal for single young professionals or the young couple!

Or choose the Maxima SaverGRID option, get the same benefits, but save up to 10% on your contributions by using network hospitals only!

Click HERE for an online quote from FEDHEALTH

In South Africa, private and public health systems exist in parallel. The public system serves the vast majority of the population, but is chronically underfunded and understaffed. The wealthiest 20% of the population use the private system and are far better served. In 2005, South Africa spent 8.7% of GDP on health care, or US$437 per capita. Of that, approximately 42% was government expenditure. About 79% of doctors work in the private sector.

In 2013, it was estimated that vacancy rates for doctors were 56% and for nurses 46%. Half the population lives in rural areas, but only 3% of newly qualified doctors take jobs there. All medical training takes place in the public sector but 70% of doctors go into the private sector. 10% of medical staff is qualified in other countries. Medical student numbers increased by 34% between 2000 and 2012.

There are more than 400 public hospitals and more than 200 private hospitals. The provincial health departments manage the larger regional hospitals directly. Smaller hospitals and primary care clinics are managed at district level. The national Department of Health manages the 10 major teaching hospitals directly.

The Chris Hani Baragwanath Hospital is the third largest hospital in the world and it is located in Johannesburg.

The current government is working to establish a national health insurance (NHI) system out of concerns for discrepancies within the national health care system, such as unequal access to healthcare amongst different socio-economic groups. Although the details and outline of the proposal have yet to be released, it seeks to find ways to make health care more available to those who currently can’t afford it or whose situation prevents them from attaining the services they need. There is a discrepancy between money spent in the private sector which serves the wealthy (about US$1500 per head per year) and that spent in the public sector (about US$150 per head per year) which serves about 84% of the population. About 16% of the population have private health insurance. The total public funding for healthcare in 2012/3 was R21 billion. The NHI scheme is expected to require expenditure of about R336 billion.

The NHI is speculated to propose that there be a single National Health Insurance Fund (NHIF) for health insurance. This fund is expected to draw its revenue from general taxes and some sort of health insurance contribution. The proposed fund is supposed to work as a way to purchase and provide health care to all South African residents without detracting from other social services. Those receiving health care from both the public and private sectors will be mandated to contribute through taxes to the NHIF. The ANC hopes that the NHI plan will work to pay for health care costs for those who cannot pay for it themselves.

There are those who doubt the NHI and oppose its fundamental techniques. For example, many believe that the NHI will put a burden on the upper class to pay for all lower class health care. Currently, the vast majority of health care funds comes from individual contributions coming from upper class patients paying directly for health care in the private sector. The NHI proposes that health care fund revenues be shifted from these individual contributions to a general tax revenue. Because the NHI aims to provide free health care to all South Africans, the new system is expected to bring an end to the financial burden facing public sector patients.

Health insurance is insurance that covers the whole or a part of the risk of a person incurring medical expenses. By estimating the overall risk of health care and health system expenses, among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is available to pay for the health care benefits specified in the insurance agreement. The benefit is administered by a central organization such as a government agency, private business, or not-for-profit entity. According to the Health Insurance Association of America, health insurance is defined as “coverage that provides for the payments of benefits as a result of sickness or injury. It includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment” (pg. 225).

Rwanda is one of a handful of low income countries that has implemented community-based health insurance schemes in order to reduce the financial barriers that prevent poor people from seeking and receiving needed health services. This scheme has helped reach 90% of the country’s population with health care coverage.

It’s a difficult task choosing an affordable medical aid plan in South Africa. Consumers are not only expected to be well informed as to the financial stability of each scheme; they have to carefully navigate reams of tedious fine print containing endless acronyms and complex medical aid jargon.

Sign up without a full appreciation of the terms and conditions and industry lingo and you could be digging deep into your own pocket. If a medical aid plan appears to be too good to be true it probably is.

Limited cover regardless of the size of the bottom line, for instance, is exactly that; medical aid cover that is limited or restricted to a certain amount per annum per beneficiary. Rack up expenses over and above that ‘attractive’ threshold and you will be liable for any shortfall!

Before you commit to a plan or package we strongly advise you familiarise yourself with the most common medical aid terms. It’s also a no-brainer to do a thorough medical aid comparison of the leading medical aid schemes in South Africa and the options they provide.

Independent medical aid brokers and consultants typically offer online comparison tools that enable instantaneous evaluations of similar products – hospital plans, hospital plans with savings, plans with limited day to day, comprehensive plans and income based network options!

The most common medical aid terms to familiarise yourself with:

  • Acute medications – medications used to treat conditions that manifest rapidly and have severe symptoms but only require short courses of medication
  • Chronic benefits – medical aid cover provided by medical aids in South Africa for defined chronic conditions or illnesses that require prolonged treatment. Each medical aid scheme will have its own chronic benefit terms and conditions.
  • Co-payments – additional payments by the scheme member to cover the shortfall between scheme rates and the actual rates charged by healthcare providers
  • Day to day benefits – medical costs incurred out of hospital at GPs, dentists, optometrists and pharmacies
  • DSPs (designated service providers) – hospitals, specialists, pharmacies and GPs chosen by a medical aid scheme to provide services to its members, often at a negotiated tariff. In some cases the scheme will not cover expenses incurred at non-DSPs
  • Formulary – a defined list of prescription medications that are covered by a specific medical aid plan
  • Gap cover – a unique medical aid product designed to cover the inevitable financial gap between medical aid scheme rates and the actual rates charged by specialists in-hospital Major medical benefits – cover for costly yet unavoidable in hospital accidents and diseases
  • NRPL (National Reference Price List) – a national guideline published by the Council of Medical Schemes listing suggested tariffs for all medical procedures and treatments
  • PMB or prescribed minimum benefits – minimum benefits that have to be provided by law to all medical scheme members in full and without co-payments. Over 270 conditions including certain cancers, heart attacks, HIV Aids and TB are listed as PMBs

Medical aid – funding your health care

Finding which of the myriad medical aid schemes plus plans from each, is “right” for your pocket and health needs is not as easy as comparing pretty brochures. For most people without the benefit of employer subsidies, price has to be their starting point to affordability.

Annually, every medical aid member is allowed to change plans and we guide clients to analyse their family’s health needs and expenses, compared to benefits offered by various options, helping bridge the ‘knowledge gap’ where the lay public, does not know.

Price increases with benefits and freedom of choice – the lowest priced “hospital” and “network” plans use contracted in providers and lists of basic primary care they cover, while excluding most expensive claims that arise from ageing, such as joint surgery, osteo-arthritis, and back/neck ailments.

Get the benefits you pay for:

Administrators and managed care third parties use complex algorithms, lists and protocols to deny claims. By managing, reviewing and helping brokers assist medical aid clients to enforce their entitlements and facilitate payment of millions of rand in benefits which routinely are denied them by their own medical aid.

Medical Aid Broker service staff will guide clients to navigate obstacles such as:

  • Families running out of benefits, because their chronic illnesses and medicines are not correctly registered, or have lapsed or changed.
  • Accessing 270 Prescribed Minimum Benefits, aside from 25 CDL chronic conditions, even when their benefits are exhausted.
  • Pre and post-authorisation of managed care – from casualty, hospitals, to prostheses and step down facilities – ensures correct payment of claims in full.
  • Group value-adds from arranging Wellness Days, courier chronic medicines, membership maintenance including Payroll and HR support with plan, scheme and family dependent changes.
  • Choosing the appropriate top-up Gap cover and savings.

Blue collar employees, the aged and disabled are particularly vulnerable to being short changed by medical aid schemes ‘rules and regulations’, whose complexity in technical English is not easily accessible. Health service providers hold clients liable, and are often frustrated by and unwilling to get involved in medical aid issues – A Medical Aid Consultant bridges these divergent interests to put your family, first.

Health Insurance – GAP Cover:

One of the amazing misrepresentations of medical schemes in South Africa is they cover “100%” of major medical expenses, whereas most families find they have unexpected amounts they have to fork out at child birth, surgery, even gastroscopies, MRI-CT scans or motor vehicle accidents. Quality top up cover for different needs, are priced in an affordable range per family per month.

In hospitals the ‘tariff Gap’ cover has evolved over the past decades to bridge the ever widening gap between what specialists and doctors charge in hospital, and the ‘scheme tariff’ paid by medical aid schemes.

Ex-Patriate Medical Insurance:

The business challenges of expanding into Africa include the lack of adequate (or sometimes, any) health facilities, ranging from primary medical and dental care, diagnostic laboratories and radiologists to first world hospital and recue facilities. Several countries have rudimentary, rural state clinics intended for locals only that are far and few between, language and access barriers which require health screening of ex-pats to manage risk. SA based medical schemes have territorial limits, with some plans offering limited “international travel” cover for brief holidays, while many provide no cover outside SA at all.

Price, terms and acceptability of payment arrangements vary, from the Africa benefits of domestic SA medical schemes, SA based and offshore based international health insurance. Local cover and facilities range from limited to non-existent, yet Africa provides commercial opportunities which many cannot ignore.

Medical Aid brokers help individuals and multinationals choose the appropriate products to suit their appetite for risk and risk-transfer cost, including supplementing occupational health with:

  • BUPA
  • Discovery Africa Benefit
  • Liberty Blue
  • Oraclemed
  • Evacuation insurance

Local benefit schemes, such as those in Botswana, Namibia, Zimbabwe and further on the continent, are supplemented with international evacuation and treatment cover, cost effectively.

International life and disability cover, as well as retirement funds, have become valuable ways of attracting, protecting and retaining a mobile, continental and global work force.