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The national Health Institute has proposed a new bill that will bring drastic changes to the medical landscape of South Africa. Although there are still significant details that need to be finalised there are changes ahead that all South Africans need to be aware of. While we attempt to demystify the new NHI Bill, what is most important to take note of is that these changes will be implemented in a staged manner with the intention to be fully implemented by 2026.

Everything you need to know about the new National Health Insurance Bill

The National Public Health Institute has proposed a new bill that will bring drastic changes to the medical landscape of South Africa. Although there are still significant details that need to be finalised, there are changes ahead that all South Africans need to be aware of. While we attempt to demystify the new NHI Bill, what is most important to take note of is that these changes will be implemented in a staged manner with the intention to be fully implemented by 2026.

We urge South African’s not to panic and make drastic changes to their medical scheme policies. Werner Coetzer, CEO of medicalaid.co.za, has this to say:

“Although reform of our existing healthcare system is necessary, South Africans should not spend their energy worrying about the new NHI Bill. They should rather focus on ensuring their existing healthcare spent is optimised according to their unique needs.”

The first question you might ask is, what will happen to my existing medical scheme? You may keep your medical scheme; however, the Bill proposes that medical schemes may no longer be authorised to cover anything the NHI covers. All South Africans will therefore rely on their medical schemes to assist with the medical needs the NHI does not cover. The Bill makes provision for cover access via authorised referral pathways; if these pathways are not adhered to, the Fund will not cover services. This means that for all practical purposes, schemes will be able to cover services in this instance.

At a recent conference held by the Hospital Association of South Africa, Dr Anban Pillay, Deputy Director General for Health Regulation and Compliance with the country’s National Department of Health, was quoted as saying that people will still be able to choose whether or not to make use of the NHI and will still be allowed to seek private medical solutions. The catch is that regardless of choice, there will still be a requirement to contribute to the NHI through taxes.

So, if the NHI doesn’t cover everything, what will it cover?

Since the new NHI Bill is still in the early phases of its implementation it is unclear what the Bill is going to cover. It has been stated that “comprehensive healthcare services” will be provided free of charge and there will be no co-payments. The new NHI Bill has stated, however, that there will be no financial assistance for conditions where “no medical necessity exists for the healthcare service in question”.

What does all of this mean if I need to see a specialist?

The Bill could be interpreted that by using the proposed referral pathways, access to specialists is possible, although how, who and where is unclear. Despite your having to pay a rather hefty tax contribution to support the new NHI Bill, it is strongly advised that you keep your medical scheme. While the exact tax contribution that will need to be made has not been finalised yet, it is important to note that there are still options for South Africans when it comes to medical schemes.

The new NHI Bill has been heavily criticised and branded a profound ideology. In theory it suggests a larger percentage of the South African population will have access to healthcare, which is a concept being heavily emphasised to the public. President Ramaphosa had this to say about the new Bill,

“It provides for a number of key elements that we would put in place to meet the constitutional imperatives that we need to provide healthcare services to all South Africans, irrespective of their socio-economic background, within the available resources.” Some South Africans have predicted that this Bill will drive our doctors away to seek better salaries and working conditions, which will lead to a crisis in healthcare. There is also speculation that the concept of a single buyer of services proposed in the Bill will lead to corruption and ultimately failure of the health system in South Africa.

Despite the major concern of a brain drain, there are other concerns:

1.  The public healthcare system is already not functioning efficiently. Although National Health Insurance promises to address the situation, many feel there is not a solid enough foundation in the public healthcare system to sustain this zealous project.
2. The state will prescribe doctors for South Africans, meaning they will be taking the choice of preferred health professionals away from South Africans.
3. There will be a huge economic impact, which seems to have been overlooked. The NHI Bill will cause many individuals working in the private healthcare sector to lose their jobs. Medical schemes all over the country will take a hit too.
4. Worst of all, to reiterate, there is a risk that the most talented and able doctors will leave the country in search of better prospects.

Despite the sceptics, many South Africans are relieved as  the Bill promises to equalise access to healthcare. “I would like to say that the NHI is here to stay. Whether people like it or not, it’s going nowhere,” said Ramaphosa in his address at an African National Congress Women’s League event.

Not only will the NHI benefit South African’s who would not otherwise have access to healthcare, but it also prevents the exploitative cost of private healthcare in South Africa, with some doctors and specialists charging much higher rates than the prescribed medical scheme rates.

South Africans are worried about how this will affect the quality of medical care in South Africa, and the burning question is who is going to pay for all of this? Well, the taxpayers, of course. They will be charged an amount “in accordance with social solidarity” through income tax, payroll taxes from employers and employees, as well as a surcharge on personal income tax. Many of the existing grants currently in place will also now be contributed to the NHI’s overall fund.

South Africans have expressed sharp criticism about the new NHI Bill and have raised many concerns; however, this does not guarantee any changes to the NHI Bill being passed. The only thing we can do now is to evaluate our medical schemes and prepare ourselves for what is to come by making sure we are covered for the procedures and doctors not covered by the NHI.

“We at medicalaid.co.za are constantly monitoring the progress of the roll-out of the NHI and will make it our mission to keep South Africans informed and guide them in their future medical scheme decisions,” says Coetzer.

Comprehensive medical scheme comparison website www.medicalaid.co.za is a well-respected and trustworthy comparison site that reviews SA’s top medical schemes in accordance with the parameters you set.

You can read more on this topic here:

https://www.news24.com/SouthAfrica/News/the-arguments-for-and-against-the-nhi-20190819

https://www.thesouthafrican.com/news/president-ramaphosa-stands-by-heavily-criticised-nhi-bill/

We can all agree that your health is not something to be taken lightly, placing great importance in the process you follow when choosing the right medical aid for you and your family. This article provides you with an overview of the South African medical scheme landscape. By the end you will have a much better idea of what to look for in a medical aid.

With over 147 private medical options from 21 Open Medical Schemes in South Africa, choosing one can be confusing and time consuming.

Medical aid may feel like a grudge purchase, especially since private medical aid premiums could take up to 10% (or more in some cases) of your monthly salary. It’s a difficult concept to grasp when everyone in your family is healthy, but you should try to see your medical aid as an investment for future health. For this reason, it is important not to base your medical scheme decision on price alone. Settling for the cheapest medical aid you come across is not a recommended strategy. There are various factors to consider in order to make an informed decision.

As a member of a medical aid you may expect cover for the following healthcare services:

• Day-to-day benefits: GP and dentist visits, specialist consults, as well as examination, diagnosis preventative care, and treatment of diseases.
• Medicine: Chronic (e.g. diabetes) and acute medication (e.g. colds and flu); and
• Major expenses: Emergency hospitalisation, ambulance services, maternity benefits, and mental health management.

Unfortunately, not all medical scheme options are equal. There are four different types of plans that you could choose from. Each has its own list of what’s included and what’s excluded. Here is a basic guide of what to expect:

1. Network options – For individuals and families with young children that need to visit the doctor more often but can’t afford a comprehensive medical aid. This type of plan includes basic day-to-day cover at affordable prices with specific network providers and in-hospital expenses submitted by network service providers. Note: the network of providers differs from scheme to scheme.

2. Basic hospital plan – Best for active, healthy families who take responsibility for their own day-to-day health but want the peace of mind that hospital expenses will be covered. This type of plan includes in-hospital expenses submitted by service providers and excludes emergency ward treatments and any day-to-day medical expenses.

3. Hospital plan with savings – A great option for individuals and families wanting peace of mind that hospital expenses will be covered and those wanting a medical savings for day-to-day medical expenses in addition to hospital cover. Here you pay a fixed monthly amount into a medical savings account. The full amount becomes available in advance for medical expenses incurred for that year. This type of plan includes in-hospital expenses submitted by service providers and day-to-day medical expenses.

4. Comprehensive plan – This option is for Individuals and families that want comprehensive cover without a savings benefit. It includes almost all medical expenses, in-hospital benefits, day-to-day medical expenses and chronic medication and excludes a medical savings account.

As you can see, the medical aid landscape in South Africa is complex. Therefore, before shopping for medical aid quotes you should review your family’s current and future health status, age of family members to be covered, unique healthcare needs and how important the healthcare services listed above are for your specific situation. In addition to this, you will also want to consider the following:

1. Restrictions (cases or situations that the scheme won’t cover)
   

   Again, each medical aid scheme and option is different. As an example, most medical aid schemes won’t pay for cosmetic surgery (except for emergencies i.e. accidental disfigurement). They also don’t cover anything relating to obesity management, as obesity is seen as a lifestyle condition that can be managed by the patient. These are just two examples. Not all medical aids have the same benefits and exclusions, some cover conditions others won’t. Restrictions are dependent on the type of plan you chose and is often linked to how much you spend. Find out about these exclusions upfront, before making your choice.

2. Annual funding limits
   

   Annual funding limits apply to all medical aids and refer to an, often, set amount paid by the medical schemes for the member’s in- and out-of-hospital expenses. Nobody ever thinks they are going to end up in a hospital but in the event that it happens, you wouldn’t want unforeseen hospital expenses to set you back financially. Having good hospital benefits could be seen as the most important decision regarding your choice of medical scheme option. In addition, you may consider adding GapCover to your plan for even more financial protection against in-hospital specialist bills.

3. Network limitations
   

   Most medical schemes have an established working agreement and negotiated rates with a specific network of health practitioners (doctors, specialists, dentists, and hospitals) to treat its members. Choosing to join a network option can save you on monthly premiums, however, note that you could be penalised or not covered by your medical scheme if you use a health practitioner outside of this network.

4. Exclusions
   

   When joining a new medical aid scheme, consumers often overlook factors such as being refused membership based on your age or current medical status. Medical schemes reserve the right to exclude pre-existing medical conditions from cover for the first 12 months of membership. This can feel like an eternity for someone that is in desperate need for medical cover. In most cases, the first three months after joining a medical scheme is considered a waiting period during which a member cannot claim for any medical expenses – consider this when switching form one scheme to another. Also note that medical schemes have the power to impose a ‘Late joiner fee’ on new members aged 35 and older. (This only applies if the person in question was not previously a member of a medical aid or those who have not belonged to a medical aid scheme for a specified period prior to April 2001.)

Medical jargon is confusing

It is imperative that new and existing medical aid members familiarise
themselves with the terms, conditions and exclusions of their chosen medical
aid benefit option before signing any paperwork. Each medical scheme has its
own set of rules and as a consumer, navigating and understanding those rules
and the accompanying jargon can be next to impossible without expert help; you
could very easily make the wrong choice. It is therefore recommended that you
use an expert comparison site such as  www.medicalaid.co.za  to help you find and compare
medical scheme benefits and price. Not only will it save you time, but it will
also give you options that you may not have even considered when undertaking
your own research. You don’t know what you don’t know, so turn to the experts
in the industry to help. Best of all, any comparisons done on the site are free.

As we come out of the winter months and the flu season, many of us have depleted our medical savings. While it’s too late to do anything about this year’s savings, there are things consumers could and should be doing to avoid this happening again next year.

 

Consumers need to break the medical savings abuse cycle

As soon as consumers realise that their medical savings is depleted before the end of the year, what usually happens is that they delay seeking the medical attention they require between the time that their medical savings runs out and 1 January of the following year.

They may for example, be tempted to leave that cavity in their tooth for a while and just ‘eat on the other side’ or put off their check-up with the gynae for a month or two. Maybe they even decide to forgo those monthly vitamins that they were paying for out of their medical savings. In doing so, by the time the new year presents itself, they find themselves with a ‘backlog’ of medical needs, some which by this stage require more medical care than if they had simply dealt with them when they occurred. The end result is that by February many have eaten into a large percentage of their annual medical savings allowance.

Ideally, when January comes around and medical schemes ‘reset’ their medical savings to its full amount for the new year, consumers should be in a position where they have no backlogged medical procedures to rush to. This sounds great, and makes a lot of sense, but how exactly can they pull this off?

 

Health first! Consumers should cut back on other expenses to proiritise their health between now and January

The goal is to remain healthy for the remainder of the year. Sounds obvious, doesn’t it? Instead of giving up those vitamins, consumers should rather give up on eating out? Looking after health needs in the short-term will help them to reduce their medical costs in the first quarter of next year and will help their medical savings to last longer. As part of a stay healthy plan, consumers should also remember to make use of their medical schemes preventative screening benefits and should focus on a healthy lifestyle which includes exercise, dieting and cutting back on bad habits like smoking and drinking. It is better for them to set aside that money as a medical saving for themselves while they are in a self-payment gap.

 

Consumers can reduce their medical costs by being smart

If consumers find themselves getting sick while in a self-payment gap, then they should consider the following ways to save on medical expenses during this period:

1. Not everything requires a doctor’s visit. In many cases, pharmacists are skilled enough to provide sound medical advice on problems such as rashes, colds or other minor everyday illnesses. Consumers should rather get an opinion from their pharmacist first before running up unnecessary doctors’ bills.
2. When consumers need over-the-counter medications such as headache tablets, vitamins, antacids or flu meds, they should first try purchase them from a supermarket rather than a pharmacy. This could save them heaps of money, as supermarkets buy in bulk and are able to pass on savings to their customers.
3. If consumers do have to spend money on medication, they should ask their doctor to prescribe a generic form of the medication needed. They should also then double check with their pharmacist that they are given the cheapest generic alternative available. Unless specifically ruled out by their doctor, they should opt for a generic as they are often a lot cheaper and do the same thing as the original brand name medications. Some generics are even manufactured by the same original brand on the same assembly line, and only the packaging is different.
4. Consumers can also avoid using multiple medicines when as an alternative, they can purchase one that takes care of all their symptoms. For example, why get one type of medicine for a runny nose, another type for a sore throat and a third type for a fever. If they ask their pharmacist, it very likely that they could get an ‘all-in-one’ medicine at half the price that will take care of all their symptoms.
5. Consumers that find themselves on regular medication, should check if their condition is listed as a chronic condition with their medical scheme. The same should be done if they receive a new diagnosis that requires ongoing medication. There are 27 chronic illnesses that all medical schemes must cover. While medical schemes don’t have to pay for the diagnosis of the condition (while the consumer is in a payment gap), as soon as you have a diagnosis, the medication could be covered by the consumers chronic medication benefits. Many people don’t realise that they need to submit their prescriptions to their medical schemes in order to claim from their chronic medication benefits and end up paying for these medications out of their own pockets. Some of the more well-known chronic conditions include asthma, diabetes, epilepsy, hypertension, rheumatoid arthritis and bipolar mood disorder. Some medical aids cover additional chronic conditions such as attention deficit disorder, depression, anxiety disorder, post-traumatic stress disorder and more, depending which medical scheme option the consumer belongs to.
6. Consumers should make use of their rewards programmes. There are a number of retailers that offer cash back, two-for-one or three-for-two specials on vitamins and other health products. Where possible, consumers should use these benefits to subsidise their monthly health expenses.

 

Plan better for the new year

Assuming consumers follow all the advice above and arrive in the new year with no backlogged medical needs, they are in a great position to plan and budget so that they don’t find themselves in this sticky situation again. While applying the same tactics and skills they have already learned, they should also sit down with their financial advisor and make sure that they understand exactly how their scheme works and how much their medical savings for the year is and where they need to fund any co-payments. Once they have a better understanding, they should draw up a medical savings budget which includes all the medicines and vitamins they may require for the year and that they purchase on a regular basis. Once they have a total spend amount, consumers should then assess if they have anything left over for those unforeseen medical expenses. If they find there is little, or no savings left or that they will run out of medical savings before the year is up, they should seriously consider which items they could pay cash for in order to minimise their financial risk should they fall ill unexpectedly. Remembering that anything they don’t spend from their medical savings will carry over to the next year, putting them into an even better situation than before.

Increasing petrol, electricity, water and food prices, and salary increases that barely cover the cost of inflation leaves the average South African consumer under tremendous financial pressure to make ends meet each month. This is evident from the March 2018 Credit Bureau Monitor which shows an alarming number of Credit Active South African consumers (50.4%) that are in arrears on their accounts.

 

Is the cost of medical aid contributing to the financial pressure of consumers?

There is a worldwide phenomenon, where the high cost of medication and new medical technology is pushing up the cost of medical expenses for the average consumer. In October last year, Fin24 reported that the average year-on-year increase of medical scheme contributions over the last 16 years has been 7.6%. According to Alexander Forbes Health, this is 1.9% higher than CPI inflation. It should come as no surprise then when StatsSA reveals that only 9.5 million people in SA are covered by a medical aid and that public clinics are still the first point of contact for most South Africans, with only 24.6% of the population using private doctors when ill.

 

Having medical cover offers consumers peace of mind, but the monthly contributions might be too much for consumers to bear!

It’s no secret that South Africans are struggling to maintain their medical aid repayments and may in many instances be considering ways to reduce this monthly expense. This is a risky decision which warrants doing research into the options available and how to reduce costs while getting the best cover available within budget constraints. Consumers that are considering cutting their medical aid from their monthly budgets to maintain other financial obligations, must carefully evaluate their options. Here are some ways to reduce medical scheme contribution costs without cancelling cover altogether:

1. Are there any other costs that can be cut?
   

   While this option may seem obvious, its often perceived by consumers that it’s easier to cancel a medical policy than to try to reduce other living expenses. Running a family budget is never easy as it requires buy-in and commitment from the whole family. Reducing unnecessary costs is preferable to losing your medical cover. As such, consumers should take a hard look at their situation and consider sacrificing some luxury items like private schooling, DSTV subscriptions, eating out and maybe even selling off a second car.

2. Investigate dropping your medical cover to a cheaper option (like a hospital plan)
   

   The number of benefits consumers opt for will determine how much they pay. Consumers should therefore investigate more affordable options with reduced benefits that their current scheme offers. The bigger the scheme, the more options available. However, consumers that are part of smaller schemes will have a more limited choice and may need to look outside their current scheme for better deals. One of the key challenges with trying to downgrade to cheaper cover is that most schemes only allow members to change to a different option once a year, usually towards the end of the year. Therefore, consumers will need to plan carefully and allow enough time to do their research, so that they can make an informed decision within this specified period. This is not a decision to be rushed.Some of the more common downgrade options that can be considered include; dropping down to a cheaper option with limited out-of-hospital cover and/or a smaller medical savings plan or no savings plan at all. There are also options available whereby consumers pay less if they use providers that are listed as part of the scheme’s doctor network. When deciding to downgrade your cover, be mindful of your own and your family’s current and possible future needs. Find an option that has suitable cover and that fits your budget.

3. Manage the dependents on your scheme
   

   If you have three children, there is no rule stating they all must be listed as dependents on your medical scheme. Most consumers don’t know this. While it may be risky, immediate savings could be made by removing healthy child dependents from your scheme and only keep those with greater medical needs covered. A better risk to take than to have no cover for the entire family. Should the main members financial situation improve, they could always add the other dependents back again. Just remember that there might be waiting periods imposed in this event.Another consideration is the cost of children that move from ‘child dependent’ status to ‘adult dependent’ status when they near the ages of 18-21 (depending on the scheme). As children change to adult dependents, their monthly contribution in some cases could double. Consumers in this situation should consider moving healthy adult children onto their own, more affordable hospital plan. Another option is to register your adult dependent as a student. As long as you have proof that your adult child is a full-time student with no income of their own, most schemes will allow for a discounted student rate. Also, some schemes only charge for three child dependents, so families with more than three children should definitely look at moving to one of these schemes.

All of these options are not as ideal as full comprehensive medical cover, and each comes with its own risks. However, the risks associated with these reduced cover options are still far better than the alternative of no cover at all.

Understanding how your medical benefits work is a daunting task for most consumers. For example, a scheme might cover a member for 100% of hospital costs at the medical fund rate. This doesn’t mean that all in-hospital costs will be covered, and uninformed consumers could still be left with an enormous bill for making use of a specialist that charges more than the medical fund rate.

Consumers wanting to explore how to get the most out of their medical aids in this tough economy should make use of the free instant online medical aid comparison tool available at medicalaid.co.za.

What are the basic principles of medical aid – how does it work?

South Africa has a dual healthcare system, consisting of public and private providers. Private hospitals are used mostly by members of medical schemes or those able to pay for these services out of their own pocket.

Medical aids are regulated by the Medical Schemes Act (1998). They are essentially non-profit organisations and belong to their members. Continue reading →

Benefits can become complicated. For your own good, here’s what you should know.

Medical schemes undertake liability in return for a premium or contribution. They are required to help their members in obtaining healthcare services and defraying expenditure for such services. The benefits that a scheme may grant must be registered in its rules. Continue reading →

Before choosing a medical scheme, and an option within that medical scheme, you need to consider the following points:

Needs and financial analysis

When deciding to join a medical scheme, first ask yourself what you can afford to spend on the monthly premium per month. Then look at your and your family’s needs. What is it that you need from your medical scheme? Continue reading →