Tips to decide on your healthcare plan as medical aid premiums increase

It is that time of the year again where medical scheme members have to decide on their healthcare options in their medical scheme plans. This is also when you find out how much more your medical scheme contributions will cost in 2025.

Medical schemes, health insurance providers and gap product companies are now announcing their contribution or premium increases and benefit changes for 2025. Therefore, it is a crucial time for reviewing your healthcare options and adjusting them where necessary.

Annele Oosthuizen, consulting manager at Alexforbes Healthcare, says healthcare decisions are rarely straightforward and you may feel overwhelmed by the choice of cover you will need for yourself and your dependants in the year ahead.

“It is essential to understand any changes to your current plan’s benefits and whether they meet your future needs. However, remember that if you are satisfied with your current level of cover, you do not have to make any changes.”

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South Africans considering cheaper medical scheme plans

She says as the cost of healthcare continues to increase, many consumers may feel pressure to reduce their expenses while still ensuring access to quality private healthcare. “You may consider switching to a more affordable plan, but it is crucial to consult your accredited healthcare adviser before making any changes.”

It is important to thoroughly understand the benefits, costs and implications because you may not have the opportunity to change your plan again until late 2025 for 2026. You will have to live with the choices you make now for the whole of 2025.

Oosthuizen says before downgrading or upgrading your plan, you should consider the long-term effect on your healthcare needs as well as your financial planning. “While buying down could save money, upgrading might offer additional benefits and peace of mind. Balance is key and professional advice is essential to avoid decisions that could lead to more future financial strain.”

To illustrate how your choices now can affect your healthcare later, Oosthuizen uses these examples”

Example 1: Downgrade recommendation

Mpho is a young single professional who chose a comprehensive option on a medical scheme. She does not have any chronic conditions now and she is not planning any medical procedures in the coming year. She used a third of her medical savings account on her medical aid. Her current contribution is R9 300 per month.

Upon consulting with her healthcare advisor and performing a financial needs analysis, Mpho’s option was downgraded to a lower plan which was suitable for her needs. Her new medical aid contribution changed to R4 500 per month, saving her R4 800 per month.

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Example 2: Upgrade recommendation

John is a professional with two dependants on his medical scheme. He asked a healthcare adviser for advice because his medical savings account was depleted in the first quarter of the year due to high day-to-day expenses.

During the year, he was diagnosed with a chronic condition and is due for a surgical procedure in the coming year. His out-of-pocket medical expenses per month are R3 800 and his medical aid contribution is R6 248 for the whole family, bringing his total medical expenses, including out of pocket expenses to R10 048 per month.

Upon consulting with his healthcare advisor, he was advised to upgrade his option to access his chronic benefits, have a bigger medical savings account and reduce out of pocket medical expenses. His new medical aid contribution will be R7 942, saving him R2 106 per month.

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Consider this when reviewing your medical aid plan

When evaluating changes to your medical scheme or health insurance, Oosthuizen says it is important to look beyond just costs. Also consider:

• Your personal health and any pre-existing conditions;
• The health needs of your dependants;
• Your claims history and potential future medical requirements;
• Changes in dependants, such as adding a newborn or removing an adult dependant;
• Your level of affordability and budget considerations.

“Also, do not forget the unexpected. Access to costly treatments may arise in the coming year and ensuring you are adequately covered for out-of-pocket expenses is critical. Your healthcare consultant can help ensure you understand your benefits and any potential shortfalls in your cover.”

Gap insurance

Medical scheme benefits should not be considered in isolation, Oosthuizen warns. “You should look into how gap cover products can offer additional cover for out-of-pocket expenses such as deductibles, co-payments and out-of-network fees.

“Gap cover is particularly useful for in-hospital treatment, where you may face significant shortfalls from specialists or anaesthetists. This added protection can ease the financial burden of unforeseen medical expenses.”

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Keep this in mind when you consider changes to your medical scheme options

When considering changes to your medical scheme benefit option, it is essential to evaluate several key factors:

• If you choose to downgrade, be aware of the potential impact on your healthcare cover, especially for future treatments.
• Seek financial advice, as medical aid benefits are a vital component of your financial portfolio and any shortfall could directly affect your financial stability.
• Review whether your current benefits provided sufficient cover this year or if you were left out-of-pocket frequently.
• Consider chronic condition coverage, the impact on your chronic medicine benefits and any upcoming planned medical procedures.
• Additionally, assess the level of out-of-pocket expenses you are comfortable with and whether you need comprehensive coverage or just a hospital plan.
• Explore if gap cover might allow for a more affordable scheme option and evaluate the long-term financial implications of waiting periods, late joiner penalties and network restrictions.

Oosthuizen says by carefully reviewing your healthcare plan and considering the advice of your accredited consultant, you can make a decision that balances your healthcare needs and financial wellbeing for the year ahead.