Gary Feldman | Seven crucial insights every medical scheme member should know

Looking at medical scheme contribution increases announced during the past month, these have varied between 5% and 18% for 2024. This does not spell good news for South Africans as they will now have to dig deeper into their pockets to meet their monthly expenses.  

Medical scheme membership is sometimes deemed a grudge purchase, therefore it is imperative to understand the scheme you are on, the benefits you are entitled to, so you can get the most out it, says Gary Feldman, Executive Head of Healthcare Consulting at NMG Benefits.

Below, Gary Feldman shares his top seven (7) essential factors that every member of a medical scheme should know:

Benefits are reviewed and updated annually

Traditionally medical schemes update their plans, benefits and contributions effective 1 January every year. Ensure that you are aware of the changes so that you are not caught off-guard when it comes to claiming. Your medical scheme should send you an updated benefit schedule as soon as changes are implemented.

Know the difference between medical scheme and health insurance

With medical schemes becoming increasingly more expensive, many people are considering health insurance products instead. These two products are not the same. The benefits you get from a medical scheme are more comprehensive, as they must cover a specified list of prescribed minimum benefits.

Medical scheme contributions currently qualify for a tax credit, while health insurance premiums don’t qualify for a tax credit, says Feldman.

Know your prescribed minimum benefits (PMB’s)

Take the time to study your benefit schedule, your condition may be a PMB condition which would impact the cover you have on the medical scheme. You may find that certain blood tests or consultations, for example, are covered. Many people under-utilise these important benefits,” says Feldman.

If you’re healthy and have a medical savings account

Certain medical scheme plans offer a medical savings account, any remaining funds must be carried over to the next benefit year. This means you can build your up medical savings account up if you are in good health and don’t claim often. If you have a traditional medical scheme nothing is carried over. So, choose carefully between a traditional medical scheme and a new generation product that includes a savings account.

Know your scheme’s exclusions and limits

An exclusion is a medical procedure that is not covered by a medical scheme, such as cosmetic surgery. Limits are also applied to benefits such as dentistry and optometry. Review your exclusions and limits and ensure the option you select meets your own overall personal health status and needs.

Take note of the late-joiner penalties and waiting periods

Late-joiner penalties usually occur if the member joins a medical scheme after age 35 and cannot provide proof of medical scheme membership, or if they haven’t belonged to a medical scheme for a specified period of time. Waiting periods can also be imposed depending on your current health. It is important to speak to a broker to see which medical scheme will best suit your and your family’s needs.

Gap cover can protect your cashflow

Medical scheme rates can be lower than the rates that specialists charge. Gap cover is a short-term insurance product that covers the shortfall between what the provider charges and the scheme re-imburses for in-hospital procedures. “It is a real value-add and is cost-effective – especially considering the peace of mind it will give you,” says Feldman.