Mail & Guardian
Mail & Guardian

Tips for choosing a medical scheme

3 min read

South Africans have more than 100 medical schemes to choose from, with hundreds of benefit options. But how do you know if your medical aid is a healthy one? The Mail & Guardian asked Aleksandra Serwa, communications manager and spokesperson for the Council for Medical Schemes, for some tips.

  • In terms of assessing the general health of schemes, there are a number of factors that should be considered, and they should be considered in relation to each other, not in isolation. Read as much as you can and ask questions.

  • Look at the solvency of your scheme or the scheme you are considering joining. The Medical Schemes Act requires schemes to maintain a solvency of at least 25%. At the same time, a solvency below 25% does not necessarily mean that the scheme is experiencing financial difficulties; consider the bigger picture.

  • Look at the reserves of the scheme per beneficiary.

  • Look at how the scheme is spending its money (it is, after all, your money). How much is spent on healthcare benefits (such as claims)? How much is spent on non-healthcare costs (such as administration)?

  • Look at the overall history of the scheme; has it been involved in any lawsuits? Pay attention to its corporate governance

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  • Has its membership been growing? How has its membership profile changed? Is it attracting young and healthy beneficiaries? When more people join a scheme, its solvency inevitably drops.

  • Consider the kind of benefits the scheme offers. How do these benefits compare with those of other schemes?

  • Have its contributions increased and if so, by how much? Consider that in difficult economic times, schemes are able to derive less investment income than in good times, meaning that they have to increase their contributions by more than normally.

  • Does the scheme communicate in an open and transparent manner, and in a language that is easy to understand? Is the information you need freely available from its call centre, on its website?

  • Serwa stresses that all schemes must provide the so-called prescribed minimum benefits or PMBs. These are guaranteed to each and every beneficiary of a medical scheme in South Africa, regardless of benefit option. Your scheme must cover the PMB conditions of its beneficiaries in full, and from the “risk pool” of the scheme, so schemes are not allowed to use your medical savings account to cover PMB conditions. There are just less than 300 PMB conditions; these are all serious and expensive, and often life-threatening. PMBs are diagnosis-driven, which means that it does not matter how you developed the condition or disease; your scheme must pay for the diagnosis, treatment and care of your PMB condition in full. These PMBs are described in the Medical Schemes Act.

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