5 WAYS TO AVOID SCARY, UNEXPECTED HEALTH BILLS

Unplanned medical bills can upset the best of budgets, and unfortunately having medical aid doesn’t mean every health problem will be covered. Check out these five ways to get the best out of your medical scheme.

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1. STUDY YOUR PLAN
Most people tend to ignore the info they receive annually about their plan. But it’s worth the effort to read it carefully to find out what cover you have. If there’s anything you don’t understand, it’s better to ask right away instead of when you’re ill. Use the call centre for client queries. If the agent doesn’t answer your question fully, ask to speak to someone senior.

Screening is an important benefit. Schemes offer certain procedures to detect conditions early and prevent severe disease, e.g. Pap smears and mammograms to detect cancer, blood tests for HIV, diabetes and high cholesterol, etc. It makes good sense to use whatever screening benefits your plan offers as they don’t cost anything and may help you live longer.

2. KNOW YOUR NETWORK
Even within the same company, different network rules apply to different plans. Medical schemes create a network of designated service providers (DSPs) specific to each plan. These can be hospitals, pathology labs, GPs, specialists and even the pharmacy where you get medication. If you use a service outside the network, you may need to make a co-payment or you may not be covered at all.

The scheme can’t force you to use their DSPs, but if you choose a non-network doctor, the scheme can refuse to pay.



3. DON’T BE SHY TO ASK – EVEN FOR DISCOUNTS
If you’re not sure whether your plan covers blood tests or X-rays, ask your doctor to check, and what the cost is, so at least you don’t get a nasty surprise later. Some doctors in the network may be covered for certain procedures only, e.g. your plan may cover a dentist consultation but not the X-rays, or a glaucoma test by an ophthalmologist, but not other eye tests. If you know that you’re going to be liable for part of the bill, ask your doctor if there’s a discount offered for immediate settlement, or if you can pay it off if it’s a big amount.

Related article: How to budget for medical care

4. PMB CONDITIONS ARE COVERED BY ANY MEDICAL AID PLAN
Even if you only have a hospital plan, or your medical savings account has nothing left for the rest of the year, your medical scheme is obliged by law to treat you for a PMB condition. PMBs involve the treatment and care of:

• Any emergency condition
• 270 medical conditions (see list here)
• 26 chronic conditions (defined by the Chronic Disease List). These include diseases like asthma, diabetes, epilepsy, hypertension and Parkinson’s disease.

So if you have a hospital plan and develop diabetes or high blood pressure, for example, the medical scheme has to cover your doctor’s visits and medication, EVEN OUT OF HOSPITAL. Many doctors aren’t aware of all the PMB benefits, but once they know you need to make a PMB claim, they can look up the correct codes and motivate your claim.



5. CHALLENGE YOUR SCHEME
If you feel your scheme has treated you unfairly, according to the South African Patients’ Rights Charter you have the right to challenge decisions made. Follow the complaints procedure of your scheme, but if you’re still not satisfied, you can approach the Council for Medical Schemes.

SOME TERMS EXPLAINED

• Designated service provider – this refers to a person (GP, specialist, physiotherapist, etc.) or facility (hospital, pharmacy, laboratory) that falls within your scheme’s first choice for treatment.
• Prescribed Minimum Benefits (PMBs) – ‘a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected.’ (Council for Medical Schemes)

Related article: 4 Health checks that could save your life

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