Picture: istock
Picture: istock

Members and would-be members of open medical schemes, which admit anyone, face a confusing array of up to 144 options. You may therefore welcome help choosing the right one, and a survey released this week offers insight.

The annual GTC Medical Aid Survey measures both the value for money you get from options in 11 broad categories, as well as the ability of schemes to sustain that value, from among the 144 options offered by the 23 schemes surveyed. The schemes admit anyone as members, except Profmed, which is restricted to professionals.

Options from Discovery Health, Momentum Health, Makoti Medical Scheme and Sizwe dominate the survey results.

Expert opinion

Jill Larkin, head of healthcare consulting at GTC Healthcare, cautioned against relying solely on the survey to pick the best cover and advised using a qualified healthcare adviser. You first need to establish which of the 11 benefit categories suit your healthcare needs and your finances. They range from the cheapest entry-level and hospital-only options, through the popular options with medical savings accounts to the most expensive comprehensive options.

Factors to consider include:

The level of cover you need for doctors and other healthcare providers who will treat you if you are admitted to hospital;

The level of cover you want for out-of-hospital expenses and how much you can afford to pay from your own pocket; and

The freedom of choice should you want to choose your own hospitals, doctors, pharmacies or other healthcare providers.

The survey compares the contribution rates of each option for what are known as risk benefits. These are benefits covered by the scheme, typically for hospital admissions, major medical expenses and the prescribed minimum benefits that every scheme must by law cover.

Right choice

Day-to-day benefits in the form of medical savings accounts or out-of-hospital accounts that are included in the scheme are typically excluded. The most competitive schemes score the highest so-called micro-rating and can be regarded as offering value for money, but only if you choose the right benefit for your needs.

The survey also ranks each scheme on a macro-rating that measures factors such as the scheme's membership size and growth, average age, financial stability as measured by its operating results, and its reserve levels and service levels.

In previous surveys, GTC weighted these factors equally, but Larkin said that this year the factors had been weighted in line with the importance GTC attributed to each.

Large schemes should be able to negotiate lower administration and healthcare costs, which should give you the benefit of richer healthcare benefits or lower contribution rates. Medical schemes are required by law to ensure that each option is financially self-sufficient - the contributions raised must cover the cost of your benefits and any non-healthcare expenses.

The scheme rated the best on these factors was Discovery Health Medical Scheme, the country's largest scheme, followed by Momentum Health. Two smaller schemes, Makoti and Genesis, are third and fourth.

Bottom of the list are Medshield Medical Scheme, Cape Medical Plan, Spectramed and Resolution Health Medical Scheme.

Larkin said smaller medical schemes often offered value for money, but had not been as successful as some larger schemes in attracting new members, and might not be able to continue offering value.

Chronic conditions an important factor

 The survey found:

63% of medical scheme options offer cover for more chronic conditions than schemes are obliged by law to cover; and

Some comprehensive options offer unlimited cover for chronic conditions.

Why is this important: schemes are obliged to cover only the cost of diagnosis, treatment and care of 25 common chronic conditions as these are prescribed minimum benefits. If you or a dependant has a condition that is not one of these 25, you may have to pay all costs out of your medical savings account or your own pocket.

Oncology

The survey found:

Nearly three-quarters of schemes offer oncology treatment above PMB levels; and

Seven options offer "unlimited" oncology benefits: Fedhealth Maxima Plus, Fedhealth Ultimax, Medihelp Plus, Medshield Premium Plus, Momentum Summit, Resolution Supreme and Resolution Millennium.

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