Watch out: medical aid scheme surprises that can cost you money

South Africans must watch out for medical aid scheme surprises that can cost them money, especially at this time of the year when their cover is diminishing after the flu season and the benefit year is coming to an end.

Understanding out-of-pocket expenses, procedural co-payments and pre-approvals will also help.

In a perfect world, having medical cover would mean zero surprises when paying for healthcare. However, Medshield Medical Scheme says whether you are preparing for a routine check-up, planning surgery or facing an emergency, knowing the ins and outs of your medical aid cover is essential.

ALSO READ: How to make the most of your medical aid scheme

Out-of-pocket expenses

Even with comprehensive medical aid, you may find that not everything is covered. Out-of-pocket expenses are costs that your medical aid does not cover, such as:

• Co-payments, where you are required to pay a portion of the total bill directly to the service provider. If you, for example, need a specific procedure like a colonoscopy, your chosen medical aid benefit option might only cover a percentage of the costs, leaving you to cover the remaining amount with an upfront co-payment.
• Non-covered services which are services or treatments that fall outside your plan’s coverage, such as cosmetic procedures or specific alternative therapies.
• Out-of-network doctors or hospitals apply when you use a healthcare provider who is not on your specific plan’s network list. You might be required to pay more or even cover the entire cost.

ALSO READ: Is health insurance a cheaper option than medical aid to get private healthcare?

Procedural co-payments before medical aid kicks in

A procedural co-payment is the amount you pay out of your own pocket before your medical aid covers certain healthcare services. Depending on your medical aid plan and the specific treatment or procedure, it can differ significantly.

For example, Medshield says, if your medical aid plan has a R5 000 procedural co-payment and you undergo a procedure that costs R20 000, you must pay the first R5 000 upfront to the service provider before your medical aid covers the R15 000.

It is therefore a good idea to always review your benefit guide for your specific plan or contact your medical scheme before the procedure to ensure you understand the requirements and how much you will have to pay.

Medical schemes have different benefit options, with some offering higher levels of cover for in-hospital procedures, which means lower out-of-pocket expenses after the procedural co-payment is met.

Understanding your specific plan’s procedural co-payments is crucial in managing your healthcare budget, particularly for planned procedures or elective surgeries.

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Pre-authorisation and pre-approval

Although we should be used to doing it by now, Medshield says one of the most common pitfalls medical scheme members encounter is failing to get pre-authorisation or pre-approval for specific treatments or procedures. Without this, your medical aid may not cover the procedure, leaving you responsible for the entire cost.

Pre-authorisation is required for planned hospital admissions, surgeries and other high-cost treatments. You have to contact your medical aid to confirm that it will be covered before treatment or, in case of an emergency, as soon after the event as possible.

“Failing to get pre-authorisation can result in significant out-of-pocket expenses. This process ensures that the treatment is medically necessary and falls within the parameters of your plan. Without pre-authorisation, you could face a hefty bill,” Medshield warns.

Pre-approval is more commonly required for expensive chronic medications or specialised treatments. It is a way for your medical aid to ensure that the prescribed treatment is appropriate and aligns with your plan’s medicine formulary.

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Difference between emergency care and urgent care?

While every second counts in an emergency, it is critical that you understand what your medical aid will cover and what not. But what exactly qualifies as an emergency and how does it differ from urgent care?

Emergency care refers to life-threatening situations requiring immediate treatment. South African medical schemes are required by law to cover prescribed minimum benefits (PMBs) in emergencies at the nearest hospital, regardless of your plan.

In true emergencies, such as heart attacks, strokes, or severe injuries, treatment will be covered, even if it is out of your scheme’s network. Check if you scheme includes emergency cover as part of each benefit option, ensuring necessary care without worrying about the cost.

However, Medshield says, it is important to note that emergency cover only applies when the situation qualifies as an emergency, while non-life-threatening conditions treated as emergencies may result in additional out-of-pocket expenses for you.

Urgent care, on the other hand, covers conditions that require quick attention but which are not life-threatening, such as minor fractures, infections, or severe flu symptoms.

ALSO READ: What you need to know about SA’s medical aid schemes and NHI

Tips to help avoid unexpected bills

Medshield gives these tips to prevent unexpected bills and medical expenses:

• Submit claims promptly: Ensure that your healthcare provider submits the claim to your medical aid within the required timeframe, as delays in submission can lead to payment issues.
• Understand your statement: Your medical aid will provide a detailed statement outlining what has been covered and what, if any, amount you owe. Check this carefully to understand why certain expenses were or were not covered.
• Follow up on rejected claims: If your claim is denied, follow up with your medical aid to find out why. Rejections are often due to missing information, incorrect codes, or failure to obtain pre-authorisation.

While choosing the right plan for your lifestyle and healthcare requirements is vital, knowing your plan’s terms can save you time, stress and money.