What to look for when comparing Medical Aids

Choosing a Medical Aid should be a well-thought-out decision. It needs careful consideration, because you and your family are relying on it financially to get you through when your health fails or you have an accident.

Here are the things worth checking when comparing Medical Aid providers, so you can make the best possible decision for your situation.

Decide what kind of cover you need

There are two main types of Medical Aid cover available in South Africa:

• Hospital Plan: covers only in-hospital expenses. Some have very limited out-of-hospital benefits, but not all do.

• Comprehensive Plan: offers everything a Hospital Plan does, plus out-of-hospital cover for doctor visits, medication and other everyday medical expenses. Some include a medical savings account (MSA) for day-to-day costs.

If you're in good health, a Hospital Plan might be enough to cover emergencies or the need for an operation. If you have a large family with frequent doctor visits, or you're an older individual with more medical needs, a Comprehensive Plan will offer more cover. It's about weighing your medical needs against what you can afford. When choosing a lower-cost option, check the in-hospital exclusions and limitations, and how these could affect you.

Compare the additional benefits

The next thing to check is the additional benefits that come with a Medical Aid plan. Schemes often include benefits for maternity, for example, but they're not all created equal. Some cover runs out three months into a pregnancy, while others pay for up to 12 consultations, which would see you through to the birth.

If you know you'll need a specific benefit, such as maternity cover or a periodic MRI scan, look for a plan that offers the most cover for it.

Check the Designated Service Provider list

The Designated Service Provider (DSP) list applies to Medical Aid plans that require you to use a specific network of providers. This is the list of professionals and facilities you can visit. Visit someone not on the list, and you'll likely need to make a co-payment, either a fixed amount or a percentage of the total bill.

Network plans tend to have lower premiums, so it's worth weighing that saving against the restriction on which providers you can use.

Look at the sub-limits

Sub-limits are the amounts a Medical Aid will cover for specific treatments or procedures. This applies to things like cancer treatment or certain operations, where the scheme pays a set amount per year, sets a limit per incident, or both.

For example, a scheme might cover one mammogram every two years for women over 40, up to a set amount. If the test costs more than that, the outstanding amount is yours to pay.

Examine the co-payments

Whether you're on a network plan or not, certain procedures and treatments will require a co-payment. For example, a CT scan might see the Medical Aid pay 60%, leaving you to cover the remaining 40%. If you have an injury that needs regular scans, it's worth checking a scheme's co-payment structure closely.

Check how much cover the Medical Aid actually provides

Medical care can be expensive, especially for in-hospital procedures, and there's no way the average South African can afford private hospital care without Medical Aid.

But what happens if your Medical Aid covers up to 100% of its own rate, and the specialist you see charges 400% of that rate? You could be in financial trouble without thousands of rands on hand. Make sure you can handle the shortfall between the Medical Aid rate and the specialist's tariff.

Consider adding Gap Cover

Gap Cover has changed the way people approach Medical Aid shortfalls. No matter what type of cover you have (hospital, savings, or comprehensive), it's worth considering Gap Cover alongside it. It covers the shortfall between the Medical Aid tariff and the specialist's tariff for in-hospital procedures, and some plans even cover certain out-of-hospital procedures, like MRIs and CT scans.

Check the scheme's solvency ratio

You might be wondering what this has to do with anything, but a Medical Aid's solvency ratio is genuinely worth checking.

It refers to a legal requirement (Regulation 29 of the Medical Schemes Act) that schemes maintain accumulated funds of at least 25% of their gross annual contributions. Think of it as a safety net that gives members peace of mind. The higher the solvency ratio, the more reserves the scheme is holding, which generally means it's in a stronger financial position.

Your easy way to compare Medical Aid quotes

Now that you've had the guided tour through what to look for when comparing Medical Aid, it's time to get started. Start your Medical Aid quote comparison today with Hippo's comparison platform. Compare 10 leading Medical Aid schemes side-by-side in just two minutes.