Start by understanding your benefits
Take the time to read the information sent to you by the scheme or your adviser. If you have access to information sessions at work or have a consultant who visits your workplace, attend the sessions to get a better understanding of your benefits.
Make the most of your cover
Depending on your medical scheme or the type of cover you choose, there are several ways to maximise your benefits. Here are some points to consider:
Hospital cover
• If your scheme has appointed a Designated Service Provider (DSP) network for hospitals, make sure you use those hospitals to keep your costs down.
• If you have a planned procedure, always check with your scheme at authorisation stage if there are any co-payments or sub-limits that will apply. A good example is joint replacements, where most schemes have specified sub-limits if you do not use their DSP.
• Talk to your doctor before a planned procedure. Check what they are going to charge and what your scheme will cover. If there is a large difference, don’t be afraid to ask if your doctor is prepared to adjust the fee, especially if you can afford to pay upfront.
Cover for in-hospital shortfalls
If your scheme applies co-payments for defined procedures or covers you at a set rate (and not the rate actually charged by the doctor), it is worthwhile to investigate gap cover. This is a separate insurance policy you can take out for you and your family to cover the difference between the medical scheme rate and what the provider has charged you (up to a maximum defined level).
Chronic illness benefits
Schemes are required to cover the medication and treatment of 26 chronic illnesses.
• Almost all options on all medical schemes apply a medicine formulary. This is a list of drugs which the scheme will cover in full. If you use medication that is not on the scheme’s formulary you may be liable for the difference, so discuss the formulary medication with your doctor to see if it is appropriate for you.
Day-to-day benefits
Try to keep your claims within specified sub-limits and find out if your option has any day-to-day benefits that are not paid out of your day-to-day sub-limits or savings (e.g. dentistry and optometry).
Additionally:
• Consult contracted or network doctors if your scheme uses them. Seeing other doctors usually results in restricted benefits or co-payments.
• Investigate if your scheme covers additional GP consultations after you have exhausted your day-to-day benefits.
• Use generic medication wherever possible – get into the habit of asking your doctor and pharmacist about this.
• Try to pay for non-critical items (such as schedule 1 and 2 drugs) from your pocket to stretch your day-to-day benefits.
Supplementary benefits:
Make sure you are aware of any supplementary benefits your scheme offers. These may include:
• Preventative care benefits, ranging from basic screenings (blood pressure, cholesterol, blood sugar and body mass index measurements) through to mammograms, pap smears and prostate testing. In some cases this extends to maternity programs, dental check-ups, flu vaccinations and more.
A better understanding of your scheme allows you to significantly stretch your benefits. Speak to your financial adviser to help choose the most suitable option for you.
'We bring you the latest Garden Route, Klein-Karoo, Hessequa news'
