Affordability is a prime concern for many when it comes to choosing the right medical aid plan.
Medical inflation consistently outpaces general inflation, so year after year employees need to balance coverage and cost.
The rising costs of medical aid premiums
Ever-increasing inflation drives the rising costs of medical aid premiums. This is further exacerbated by high service provider fees, a growing burden of disease, increased hospital admission rates, the adoption of new medical technologies, and the mandatory solvency requirement of 25% for schemes.
Additionally, benefit enhancements and the battle against fraud, waste and abuse all contribute to premium hikes.
Schemes typically consider the following factors when deciding on premium increases:
- CPI
- tariff increases ranging from 1% to 3% above CPI
- utilisation rates with an increase of 2% to 3%
- solvency requirements
- additional costs if the scheme is adding new benefits
Balance affordability and comprehensive coverage
While budget-friendly medical aid options may seem tempting, selecting a plan solely based on the lowest premium can lead to potential pitfalls.
The adage ‘you get what you pay for’ holds true in this context. Less expensive options often come with limitations, such as the requirement to use specific network hospitals and doctors. Some may exclude high-cost procedures or impose high co-payments. Chronic condition coverage may be limited to prescribed minimum benefits, and day-to-day cover may only include primary healthcare.
Here are tips to consider when choosing a medical aid plan:
- Assess health status yearly
New members or those with breaks in cover may face waiting periods for pre-existing conditions. Yearly reviews help ensure that members are on the appropriate plan, taking into account potential surgical needs, diagnostic procedures and specific health conditions. Try not to join medical schemes only when you need it or leave when you feel you no longer need it.
- Find out how much specialists charge
In-hospital coverage intricacies can catch members off guard. While medical aid options typically state coverage at 100% of the scheme tariff, specialists may charge significantly higher rates, leaving members with unexpected expenses. Understanding which specialists are contracted with the scheme and the potential for co-payments is essential.
- Assess the scheme’s financial stability
This is a critical factor to consider when researching medical aid options. Operating results, claims ratios and solvency levels provide insights into a scheme’s financial health. Consistent losses or declining solvency could raise red flags about pricing accuracy and claims control. Demographics and scheme size are linked to financial stability. Larger risk pools offer stability and negotiation power with providers, while ageing members may increase claims costs over time.
- Review service levels
Service levels, including customer call centre efficiency and claims processing, greatly affect member satisfaction. Members should inquire about response times, the capability of call centre agents, call resolution rates, claims turnaround times and the use of technology like AI and robotics.
- Find out how managed care programmes work
Managed care programmes aim to balance quality and cost but come with restrictions on treatment protocols and provider choices. Members must understand the entry criteria and adherence requirements.
- Review yearly contribution increases
These can impact members’ financial planning. Higher-than-average increases can strain budgets and necessitate plan changes or downsizing.
- Assess technological innovation for a modern healthcare experience
This is transforming healthcare, with members seeking online tools, telemedicine, wearable devices and electronic health records.
- Find out the benefits and costs of loyalty programmes
They may come at an additional cost and require active participation. Members should consider the long-term commitment and health checks required.
- Find out how chronic conditions are covered
Members must find out if their scheme covers their diagnosed condition and prescribed medicines, and if it requires any preferred providers.
- Seeking advice from independent healthcare advisors is beneficial
It’s essential to verify their qualifications and accreditations. Commission caps and regulatory measures ensure advisors prioritise members’ best interests.
In conclusion
Choosing the right medical aid plan requires a thorough understanding of the complex 
This is why it helps to have an independent healthcare consultant to provide expert employee benefit insights and quality advice. Ultimately, proactive research and a tailored approach are key to securing the best medical aid plan for one’s unique needs and circumstances.
Nicole Lombaard | Consulting Manager | Alexforbes Health | mail me |