Medical Aid, Health Insurance or Gap Cover?

Choosing an appropriate medical aid scheme can be overwhelming.

While the country is experiencing a grim economic period, tightening your belt is essential. However, cancelling your medical aid should be avoided as this cover will protect you financially if you have unexpected medical emergencies. Rather look at how you can make your medical aid and savings last longer.

In difficult times, the first thing many people do is look for a more "budget-friendly" plan – usually the most alluring is a health insurance plan. However, it is important to note that while health insurance may cover unforeseen medical aid care, it is not as extensive as medical aid cover and may not cover the prescribed minimum benefits (PMBs) that have to be covered on all medical schemes.

The best way to make your medical aid go further is by understanding how various benefits and components of your medical aid work and what they cover.

Primary healthcare insurance cover is designed to offer affordable primary healthcare cover to the previously uncovered population. It should be noted that these products often do not cover all hospitalisation costs and they are not necessarily a viable substitute to a medical aid scheme.

Gap cover is a separate type of healthcare insurance cover and is designed to cover certain medical costs that your medical aid may not cover while you are in hospital. It is also important to understand that these products are not medical schemes and can only be offered in addition to a valid medical scheme membership. Cover will depend on the particular product and, depending on design, it may not include:

  • Co-payments for procedures when you are in a waiting period
  • Routine medical check-ups and out of hospital visits
  • Home-based care
  • Medical procedures that are done by non-network medical service providers.

Gap cover could, however, cover:

  • Some of your casualty unit costs
  • Co-payments for certain specified hospital procedures
  • Cancer treatment co-payments to an extent

The yearly increase on medical aid cover can stretch your budget as premiums increase, but make your medical aid go further by doing the following:

  • using network doctors, optometrists, hospitals, dentists and network-approved pharmacies
  • visiting your general practitioner first instead of going directly to a specialist
  • taking medication that forms part of your scheme’s medicine list or formulary to avoid co-payments. 

Generic medication can also dramatically reduce how much you spend on medication, so ask your pharmacist for advice when filling prescriptions.

The best way to make your medical aid go further is by understanding how various benefits and components of your medical aid work and what they cover.

Speaking to a healthcare adviser is the best possible way to ensure you get the very best out of your cover, as they can advise on your individual needs when choosing a plan that can ultimately save you in the long run. No two individuals are alike and therefore what they require out of a medical aid plan would differ, so consult a professional about cover that suits your personal budget.

By: Annelé Oosthuizen, senior consulting manager at Alexander Forbes Health