Feb 2015

How to choose medical care

Written by Council for Medical Schemes
Private medical care can be expensive and choosing the right medical scheme for yourself and your family is not easy.

There are more than 8,7 million people who are medical scheme members while many more intend to join the 87 registered schemes in the country. People join medical schemes because they want security for both chronic and unplanned medical incidents that may need specialist care, often running into thousands of rands.

According to Daniel Lehutjo, Acting Chief Executive Officer and Registrar of the Council for Medical Schemes (CMS), there is a perception that medical scheme premiums are expensive and unaffordable for ordinary people.

“The reality is that many of the 24 open schemes currently do have affordable entrylevel plans that cater for the so called ordinary people. Several thousand petrol attendants, food workers and farm workers enjoy medical cover through medical schemes thereby proving that basic medical care is not out of reach for many people as they might think.”

The CMS came into existence through the Medical Schemes Act, 1998 (Act 131 of 1998), to protect medical scheme members. The CMS’s mandate is to regulate the medical schemes industry and ensure that people receive fair and equal access to medical care. The CMS has to inform people about their rights and solve disputes related to medical schemes for free.

“It is important to choose the right medical scheme not only based on price but by doing research to ensure that the scheme meets the needs of you and your family,” said Lehutjo.

Choosing a medical scheme

This advice can be used by potential and current members of medical schemes who have the option of selecting a different benefit option at the end of each year. Here are a few tips:

  • Identify a few schemes and ask for information about their benefits, contributions, limitations and exclusions.
  • Compare the advantages to determine which one meets your needs.
  • Besides the health care benefits also find out what the scheme’s reserves are (solvency ratio), and non-health care costs such as administration costs, to ensure they are in good financial health.
  • Understand what prescribed minimum benefits (PMBs) are and under what circumstances the chosen scheme provides such cover for you.

“Here you can look at designated service providers and their proximity to you as well as other networks that provide benefits to members,” said Lehutjo.

He added that people should ensure that the scheme they are considering is duly registered in terms of the Medical Schemes Act of 1998. The names, addresses and telephone numbers of all registered schemes are published on the CMS website. The list is also published annually in the Government Gazette for general information. The Office of the Registrar will also provide you with information on registered schemes such as their financial statements, etc.

Current medical scheme members

If you are already a member of a scheme, read all the material such as options to change plans. Ensure that you understand how the benefit options operate and choose according to your health care needs and what you can afford. The registered rules of medical schemes fully disclose detailed information regarding the relevant benefits and contributions. It is essential that you obtain the rules of the scheme or a summary of the rules to verify all information relevant to enable you to make an informed choice.

“Some people choose to make use of an agent or broker. Remember it is not compulsory to use a broker, but if you do ensure that he/she has been accredited by the CMS and that your selection of a scheme is based on informed consent,” Lehutjo said.

For more information on how to choose a medical scheme, PMBs, rights of scheme members and the complaints procedure, call 0861 123 267 or visit www.medicalschemes.com or email information@medicalschemes.com

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