Reo Botes | Don't let the jargon stop you from finding the best medical cover

Having some form of medical cover is essential to enable access to quality private healthcare in South Africa, but making the right choice of cover for your needs and budget can be a daunting task. There is so much jargon surrounding the industry, from waiting periods, penalties, exclusions, limitations of pre-existing conditions to application of formularies, preferred providers, and tariff codes, to name a few.

Understanding these terms is key to selecting the most appropriate option for you and your family, so it is important not to let the complexity put you off. Working with an advisor can help you decipher the technicalities and find the best fit to protect your health and financial wellbeing.

Understanding the fundamentals

Choosing the right cover starts with understanding the fundamentals, including the plan cover, benefit sets and the price. Medical insurance is not the same as medical aid; medical insurance is a short-term insurance policy, while medical aid is governed by the Council for Medical Schemes, and the way they cover treatment will differ.

The premiums also differ as a result, with medical insurance offering a more affordable option with less comprehensive cover. It is therefore essential to know what you are paying every month and what this payment covers in terms of healthcare. Then you can decide whether what you are paying for aligns with your needs and your affordability factors.

Once you have selected a cover option, you need to understand certain terms. Waiting periods refer to the length of time between taking out a policy and when certain conditions will be covered; for example, a new policy might have a waiting period of three months before you will be covered for day-to-day medical expenses, while emergencies will be covered immediately.

This also applies to pre-existing conditions, which are illnesses or factors affecting your health that you already knew about at the time of taking out a policy. For example, if you have an already-diagnosed back problem, treatment relating to this may not be covered for the first year of your policy. Exclusions are specific services, treatments, or conditions that the selected plan does not cover. These are outlined in the policy, meaning the provider won't pay for these items, and that you as the member will have to cover the costs yourself.

There are also terms like preferred provider or Designated Service Provider (DSP) that you need to understand; these refer to the doctors, hospitals, and medical providers that form part of your healthcare network, with whom your cover provider or administrator has an agreement to cover your treatment. Chronic conditions are long-term health conditions that are covered according to certain well-defined treatment plans and use medications on a formulary, or a defined list of internationally accepted medicines used to treat these conditions.

Tariff codes also known as (procedure codes or billing codes) are standardised numerical codes used to identify specific medical services, procedures, or treatments that healthcare providers offer. These codes ensure that claims submitted to either the medical aid schemes or medical insurer are consistent, accurately priced, and processed efficiently.

Do your research

While the list of terms and terminology can seem overwhelming, a bit of research can help you understand what they mean in general. However, understanding how they apply to you and your unique circumstances is more challenging. This is why it is important to work with an advisor or broker and to share information in good faith to allow them to assist you based on your unique health exposures.

These knowledgeable and experienced individuals understand the available products and the industry. They will assist you to make the best-informed decisions Most providers will also supply information via, Explainers, FAQ's and guidelines, alongside member information days which can assist with these terms and understanding the benefits supplied.

Additional questions and checks may include things like: are there network providers in my area, and are there copayments involved? Do the doctors in my network dispense medicine as well, so I can save on these costs at the pharmacy? How are providers contracted, and how are they covered? Will I need to pay the provider upfront and claim back, or does my provider pay them directly? If you travel a lot, does your insurance have network providers in the areas you travel to? This information is easily available, and your broker or advisor can help. Asking questions and educating yourself while being open and honest with your broker or advisor is vital.

Selecting the right medical insurance is a personal decision, and it's important to assess your risks and ensure that your selected plan, covers these risks. Should any part of the medical insurance policy or cover be unclear, it's crucial to seek clarification by asking questions.

Don't be intimidated by jargon and acronyms; this is what your broker or advisor is there for – to share their knowledge and help you make educated and informed decisions. Regulations require advisors to give you the best advice they can and will use the information you give them to align your affordability and requirements with the appropriate benefits and best fit cover.

*Reo Botes is Managing Executive of Essential Employee Benefits.