Which are the top medical schemes?

 GTC Medical Aid Survey 2017Discovery and Momentum medical schemes top the tables in the 2017 GTC Medical Aid Survey across most plans. The extensive survey, conducted by financial advisory firm GTC, takes various criteria into account when ranking the scheme options.

Jill Larkan, head of Healthcare Consulting at GTC, says when selecting a medical scheme for clients, they always consider the long-term sustainability of the fund.

“On the micro level, we compare the premiums in the relevant categories and then we look at ten major macro criteria,” says Larkan who explains that the macro criteria provide a good idea as to the sustainability of the fund and whether or not the fund will be able to contain premium increases going forward.

The GTC Medical Aid Survey looks at: the number of members on the scheme; growth in membership year on year as well as over a three-year period (indicating trends developing); year-on-year growth within the pool of members over a one- and three-year pool (indicating whether one scheme was able to attract members from another); solvency ratio; net healthcare results over a one- and three-year period; the average age of the members; and the number of complaints received on the Hello Peter website. A fund is more likely to be sustainable if it has a solvency ratio of at least 25%, a relatively low average beneficiary age (37 years or less), and a broad membership base.

Just looking at the cheapest fund does not take into consideration the sustainability of the fund. If a fund is experiencing higher claims than premiums, it will eventually have to incur higher premium increases or it will collapse.

The survey compared scheme options across different levels:

Entry level

The top-rated schemes for entry-level plans include: (within the state-only, low-salary and mid-salary banded categories)

  • Makoti Primary (state-only for hospital)
  • Momentum Ingwe (state-only for hospital)
  • Discovery KeyCare Access (state-only for hospital, excl maternity)

These plans are aimed at young first-time workers, and provide in-hospital and out-of-hospital benefits but within a limited list of doctor and hospital networks as well as medications. Some of the schemes allow members access to private hospitals as well as GPs, dentists and opticians for example. Most plans charge based on the salary earned, so although the benefits remain the same for all members, the higher-income earners are cross-subsidising lower earners.

Hospital-only plan

The top-rated schemes include:

  • Discovery plans: Essential Smart, Essential Delta Core and Coastal Care
  • Genesis Private Choice
  • Momentum Custom

These provide for in-hospital cover only but include out-of-hospital cover of chronic illness and prescribed minimum benefits as set out by the Medical Schemes Act.

Saver plans

The top-rated schemes include:

  • Discovery Essential Delta Saver, Classic Delta Saver and Coastal Saver
  • Momentum Incentive
  • Topmed Active Saver

A Saver plan provides in-hospital benefits at various levels, as well as access to out-of-hospital benefits via an out-of-hospital benefit or savings account.

Comprehensive plans

The top-rated schemes include:

  • Momentum Extender
  • Discovery Essential Delta Comprehensive, Classic Delta Comprehensive and Essential Comprehensive
  • Topmed Executive

These plans have unlimited above-threshold benefits or unlimited secondary out-of-hospital benefits.

How to select the correct plan

When looking at the various schemes and options, you should obviously consider the affordability of the monthly premiums, but perhaps more importantly, you should ensure that the benefits offered suit your needs.

What is the level of hospital cover?

Over three-quarters (76%) of plans offer only 100% medical scheme rate cover for in-hospital costs.  Only 28 plans offer 200% and only 7 offer 300%. If you’re going for one of the 100% options, you should consider taking out gap cover insurance as part of your medical cover, as most private hospitals charge above the medical scheme rate, according to Larkan.

What are the annual limits?

Five medical schemes (Commed, Topmed, Momentum, Compcare, and Hosmed) still impose overall annual limits on risk cover which are aimed to manage the schemes’ risk exposure. If there are limits on your plan you need to understand what those are and how they affect you.

Until what age is my child covered?

Most schemes cover children up to the age of 21, however some schemes allow a child to remain a dependent until the age of 28. More than half of the schemes only charge for either the first two, three or four children. For example, if your plan only charges for the first three children and you have four children, your fourth child is covered for free.

What chronic benefits are offered?

Over 60% of medical plans offer additional chronic illness benefits over and above the prescribed minimum benefits. These tend to be higher-end plans, with some comprehensive plans like Makoti Comprehensive and Profmed’s ProPinnacle offering unlimited chronic illness cover.

What maternity benefits are provided?

Most schemes provide for maternity benefits from the risk portion and not from savings accounts. Larkan says this encourages younger members to retain their cover and to ensure they are on the right plan as maternity benefits have no impact on their savings account. Check what additional benefits are provided, as these vary by plan. For example, nearly 60% of plans offer specialist consultations, only 20% offer antenatal classes and 60% offer scans.

What is the cancer cover?

Nearly three-quarters of plans offer oncology treatment levels above the prescribed minimum level, with seven plans offering unlimited cover – these include Fedhealth Maxima Plus and Ultimax, Momentum Summit and Medihelp plus. If your scheme does not have extensive cancer cover you can top up through gap cover insurance.

What else is covered from risk and not savings?

The more bills paid from risk and not savings means that your day-to-day savings last longer. Around 30% of schemes pay for contraception from risk and nearly 50% of schemes cover specialised radiology, such as MRI and CT scans, from risk. Many schemes also cover emergency hospital visits or trauma events from risk.

Most schemes now cover preventative screenings from risk cover, including flu vaccinations, pap smear, cholesterol tests and mammograms. This encourages members to take their annual tests as it does not affect their day-to-day medical savings.

Student schemes

Six medical schemes specifically offer student plans aimed at full-time students. For less than R350 per month, a student can have hospital cover and visits to GPs and dentists, for example. The top three rated schemes are Makoti Primary, Topmed Network and Momentum Ingwe. Makoti charges R225 per month but only provides state hospital cover. Momentum (R335 per month) and Topmed (R319) include private hospitalisation.

This article first appeared in City Press.

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