Learn about the advantages and disadvantages when it comes to choosing network cover or the free choice option for medical schemes.
Medical schemes offer many options to suit different needs. A common one is network cover as opposed to free choice. Each has advantages and disadvantages, so it's important to understand what these are so you can choose the medical aid or hospital plan that best suits your needs.
The fact that you're reading this means you already know that medical care can be expensive and that you need to be well-prepared for any unexpected costs. To address this in an affordable way and still offer comprehensive cover, medical schemes can negotiate discounted rates with healthcare providers.
When a doctor or specialist agrees to charge a negotiated fee for their services (usually 100% of the Medical Aid rate), they become in-network doctors. If you have network cover, you can choose from a pool of these doctors for any planned procedures and have the peace of mind of knowing that these costs will be covered in full, and you won't be liable for a co-payment. These claims are often submitted directly to the medical scheme by the practitioners, which is an added benefit in that it removes the burden of paying and claiming back.
Out-of-network doctors are simply those who haven't agreed to a reduced rate (and may charge 200% or as much as 600% of the medical aid rate), and don't fall under network cover.
Networks aren't only for doctors
Negotiated price benefits aren't just for doctors and specialists; they can also apply to hospitals and pharmacies. For example, a hospital plan or medical aid plan could specify which hospitals are in their network, and which they will then pay for in full.
Alexia Graham, a director at Hippo Advisory Services, adds that some medical aid products have network rules across all benefits, and some only have hospital networks, so make sure you clarify this when choosing your cover.
You're probably wondering what happens if you're on a network plan and want to go with an out-of-network option for a planned procedure. For example, you may have a preferred doctor who has been treating you for years, or a specialist could be strongly recommended for your specific needs. Maybe the maternity hospital of your choice is conveniently close to your home but doesn't form part of your hospital network.
In these instances, you can still use the out-of-network option, but you can expect additional costs. For doctors and specialists, this will be the difference between the negotiated rate and their actual rate. For hospitals, this would be a non-network co-payment which would vary depending on the scheme.
Remember that a non-network co-payment does not apply when you need to be admitted to hospital in an emergency. An event is classified as an emergency when there is a sudden, unexpected onset of a health condition that needs medical or surgical treatment immediately to avoid serious injury or death. For unplanned admissions, network restrictions fall away, and you should be covered in full as this is a prescribed minimum benefit. Once stabilised, you will be moved to a network hospital.
If you don't want any limitations when choosing your healthcare providers, you can go with a free choice plan. These plans do not financially incentivise you to use specified networks. However, keep in mind that you may still need to make co-payments for some treatments, and your monthly premiums will be higher.
Read more: What to Look for When Comparing Medical Aids
Graham reveals that network plans can save consumers an estimated R500 in premiums each month. This saving means that your benefits can go further, offering you great value for money.
"Some plans also offer additional benefits if you have exhausted your savings account cover and have claimed within the network rules," she adds.
However, Graham cautions that you need to be clued up on exactly what you're signing up for. "An important fact to consider is that the extent of the networks differs across the network option products, so there are plans with larger networks than others," she explains. "This becomes an important consideration when choosing a product as you need to ensure that a) the network aligns with the area you live in and b) are there other products with a broader network at the same price?"
If you need help comparing different medical aids or hospital plans, you've come to the right place. Hippo's online tool enables you to compare the features and benefits of different plans side by side, giving you a better understanding of exactly what you're buying into. It's quick, it's easy, it's free — and it's just one click away.
This article is for informational purposes only and should not be construed as financial, legal or medical advice.