What you should know before switching your medical aid

Here are some tips when switching medical aids, or moving to a new medical aid plan:

1. You can only upgrade to a better plan at a certain time of the year

Members of open medical schemes can switch to a new medical scheme at any time, although you may be subject to waiting periods on the new medical scheme. These waiting periods will be based on the period that you have belonged to a medical scheme, and your answers to underwriting questions.

Members can downgrade their plan choice within their existing medical scheme at any point in time. You have the option to upgrade your plan choice annually on 1 January.  Plan upgrades at any other time during the year is not allowed, to protect members against the costs of selective upgrades.

Whether a member is considering an alternative medical scheme, or a change of plan in their current scheme, it is advisable to contact your financial adviser, who can advise you on your available options.

2. Factors to consider if you are downgrading to a less expensive option

The most critical consideration is the medical needs of the member and their family. Although a plan downgrade may save you monthly contributions, the additional out-of-pocket expenses to continue to meet the medical needs of your family must be considered as well.

Members should consider network options, since these typically offer the same benefits, but within a defined network of healthcare facilities and healthcare professionals. Network options also offer a discounted contribution based on the network efficiencies.

Members who do decide to downgrade their plan choice must be fully aware of the impact it will have on their future cover for healthcare. This may include lower levels of day-to-day healthcare services, or lower levels of cover for major medical expenses like cancer and medical emergencies.  Members should make alternative provision for the financial impact this may have.

Financial advice is critical for this decision – it may be possible to maintain the same plan choice by allowing an accredited financial planner to reconsider the cost of the member’s entire financial planning portfolio, including life and disability insurance, and not just the healthcare component of that.

3. Crucial factors to consider before joining a medical aid

The considerations are the same as for an existing member who is considering a change in plan, i.e. medical needs, network options and provision for benefits not available on the plan they can afford.

4. What factors to look for in a new plan, but still with the same medical aid company? For e.g. if you haven’t been to the GP in a year and are in top health, what should you consider?

Members that move to a plan with lower levels of cover for day-to-day healthcare services on the basis of their current health must be aware of the impact the move may have on their cover for major medical expenses, including cancer.  Although you may save in contributions, you may compromise yourself when it comes to the cover for really expensive medical events that are not really related to your current levels of health.

5. What depletes your savings account and how to avoid this

The items that can deplete your medical savings account, or lead to avoidable co-payments and out-of-pocket expenses include: visiting doctors, pharmacies and healthcare professionals outside the network covered by the member’s plan; claiming for over-the-counter medicines; and doctors that charge above the rate covered by the medical scheme.

Discovery Health Medical Scheme provides members with digital and telephonic services to locate a healthcare provider whose services are covered in full by their plan.

Medical aid in South Africa provides financial cover for medical expenses for members who pay a monthly contribution for this cover.

Medical aid covers members’ healthcare costs such as hospitalisation, treatments and medicine. These costs are covered according to the rules of the medical scheme and the member’s medical aid plan type. These rules ensure that members are fairly cared for.

All medical schemes in South Africa are governed in accordance with the Medical Schemes Act 131 of 1998, and are regulated by the Council of Medical Schemes.

Medical aid contributions are paid to medical aid schemes (including Discovery Health Medical Scheme) and are pooled and safeguarded. These schemes are operated on a not-for-profit basis.