Choosing medical cover for your parents is no easy matter. There are several factors to consider such as their medical needs, their financial situation, the facilities close to them and what level of cover would be appropriate.Medical cover for a parent can cost anything between R1 000 and R5 000 per month, not taking into account late-joiner penalties. It depends on the level of cover (hospital plan or full medical scheme) you choose, and the specific option on the scheme. Many people who are healthy all their lives suddenly need extensive medical care when they become elderly. Private healthcare is enormously expensive, and few can afford to foot that bill themselves, even if they are wealthy. In fact, fewer than 10% of retired South Africans can afford to maintain their lifestyle post-retirement, and often high medical scheme contributions is one of the first casualties. Q. Can I put my parents on my scheme as dependants? A. Yes, you can. In fact, any member of your family can qualify as your dependant if you can prove that they are financially dependent on you and that you are liable for family care and support.This includes spouses/partners, parents, grandparents, children, step-children, the child of a spouse, grandchildren and in-laws. Once a child has left home and is self-sufficient and working, they can no longer be registered as a dependant. Q. Is a hospital plan enough for a retired person? A. It’s not ideal, but it is a lot better than no cover at all. Most really expensive medical treatments take place in hospital, and a hospital plan will cover your parents for 270 prescribed minimum benefits, which cover 90% of hospital procedures. But as one grows older, medication costs and certain out-of-hospital expenses can become substantial. Q. What is the principal difference between a full medical scheme and a hospital plan? A. A full medical scheme covers in-hospital and portions of out-of-hospital treatment, whereas most hospital plans only kick in once you are admitted to hospital. That means visits to the GP and all day-to-day medical treatment, as well as acute medication costs, will be for your own pocket.But the monthly contributions for hospital plan membership are also substantially lower than those for full medical scheme membership, which may be a consideration if your parents are under financial pressure. Q. Can a medical scheme refuse to accept my parent as a member? A. No, they can't, but they can subject them to waiting periods before they can claim: usually a three-month general waiting period, and also a 12-month condition-specific exclusion for the treatment of certain pre-existing conditions. Q. What is gap cover and how does it work? A. This pays a multiple of the difference between what your scheme pays, and what a private doctor or specialist charges in a hospital. This is an insurance product, and your parents need to belong to a scheme in order to qualify for gap cover. Just check, as some gap cover products have a cut-off age for applications. It is not expensive, and can make a real difference in a medical crisis. Q. What does it mean when it says a plan covers 100% or 200% of the medical fund rate? A. That is the rate that a scheme will pay for certain doctors, specialists or procedures. It might be substantially less than the rate private doctors or hospitals charge, so if you can afford it, take the 200% of medical fund rate, otherwise you could be landed with large co-payments for your parents. Q. How does the payment for chronic medication work? A. There are 25 chronic conditions for which all schemes (hospital plans included) have to pay. They usually have a medicines formulary listing the medications for which they will pay. These are often generics, which are much cheaper than brand medications – but they are equally effective.Some schemes have a fixed amount they will pay per condition. You need to register your parents with the scheme if they have been diagnosed with any of these chronic conditions before they can claim for this medication. Q. Does a full medical scheme pay for all medical treatment? A. No. If your medical savings account for day-to-day expenses has run out, you could find yourself in a self-payment gap. Until then, a scheme will pay for treatment at registered healthcare providers either partially or in full, depending on your option. Some schemes have above-threshold benefits if you have gone through your self-payment gap. Q. What is a designated service provider and how will it affect the choice of scheme? A. These healthcare providers (hospitals and private doctors) are on a network and undertake to charge the medical fund rates. So if you use network hospitals and doctors, there should be no co-payments. Healthcare providers outside this network could charge substantially more, and this will be for your own pocket. Check to see if there are any DSPs in the area where your parents live – there is no point in paying for medical scheme membership if they are unable to access the care. Q. What if they have never belonged to a scheme? A. If your parents have never belonged to a scheme, they can be made to pay up to 75% of the scheme contribution as an ongoing late-joiner penalty. Q. What if there has been a break in their medical scheme membership? A. The scheme will calculate the late-joiner penalty based in the number of years that your parents did/did not belong to a scheme. They will need to have the paperwork to prove their membership. Q. Does it cost anything to change schemes? A. No, it doesn't. The only possible costs are if you have to pay for something while your parents are subjected to a waiting period. Q. Do pensioners pay more or less on contributions than other medical scheme members? A. Pensioners pay the same as everyone else. A small number of options take income into account when calculating contributions – proof of income will have to be provided. Q. Do my parents’ former employer/s subsidise their medical scheme contributions? A. Some do (such as GEMS), but this is becoming rare in the private sector where, increasingly, your scheme contribution is part of your total cost-to-company package. Check whether your parents receive a subsidy from former employers – they could lose that if you put them onto your scheme. Q. Are my parents’ medical expenses tax deductible? A. Yes, if you are supporting them entirely. But this is not the case if they are furnishing their own tax returns (in which case they will probably not qualify as dependants on your scheme anyway). To get a quotes for suitable medical aid options please contact Namhla or Tammy or in our health and wellness department email :health@daberistic.com tel no: (011) 658 - 1333 Source : Finance 24
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Imagine finding out that your pharmacist or doctor has been arrested for submitting an account for care that was not administered, or for over-billing for supplies and services. Imagine finding out that he or she falsified patient data to obtain a higher payments from medical schemes, or had been paid kickbacks to refer patients to a specific specialist or clinic. These are some examples of medical scheme fraud, which exacts a human and financial toll on our nation. The loss of funds not only compromises the financial integrity of medical schemes, but also undermines their ability to provide healthcare services to the more than nine million people who depend on schemes. Medical fraud has directly affected the quality of health care and put some of the most vulnerable patients at risk. Many patients are harmed as a result of unnecessary procedure. Medical schemes and their administrators are having to spend substantial sums of money on analytical software capable of detecting irregular claims. Fraud and abuse are rife. It is estimated that at least 10% to 15% of all claims are fraudulent, abusive or wasteful in nature. In a R150-billion industry, that is a substantial expense. Fraud and waste are defined as intentional deception or misrepresentation, misreporting data to increase payments, paying kickbacks to providers for referring patients for services or to entities, or stealing providers’ or patients’ identities. Examples of fraud are billing for non-rendered services or supplies, misrepresenting diagnoses to obtain payments and accepting kickbacks. Abuse includes practices of providers, physicians or suppliers of services that are inconsistent with accepted medical practice, or that are not reasonable and necessary, resulting in unnecessary costs to medical schemes. One of the most common types of abuse involves the miscoding of claims. Every year, medical schemes are cheated out of billions of rands, which results in higher contributions and co-payments for members. Healthcare fraud and abuse are hard to contain because of a variety of factors, including the volume of claims associated with a single healthcare event and the emotive nature of “the story” linked to every claim. Payment by the medical scheme has become an expectation, a right that cannot be denied. Solutions for stopping medical fraud include: making better use of technology; higher penalties; improved provider enrolment procedures; greater rewards for reporting fraud; educating beneficiaries; and empowering patients and providers so they can identify and report fraud. Here are some important steps that members of medical schemes can take to ensure that they do not become victims of medical fraud.
Source: Personal Finance With this year’s National Budget, as announced by Minister Pravin Gordhan on Wednesday 22 February 2017, the following fast facts as it relates to the healthcare industry are highlighted for your attention
Source: Resomed It’s tempting to want to splurge on over-the-counter vitamins and supplements or some other lifestyle item when medical aid benefits, limits and savings accounts get renewed come 1 January each year, especially after the costly festive season spending. GTC’s Head of Healthcare Consulting, Jill Larkan, cautions however that members should spend medical aid savings prudently and use benefits wisely, particularly in the early part of the New Year. “The governing body of this sector - the Council for Medical Schemes (CMS) - recently released commentary urging members to make medical aid benefits last longer,” says Larkan. “We completely concur with the CMS. Spending sensibly from the outset helps to extend the availability of funds later in the year, while ensuring you are able to retain a positive balance in your savings account for as long as possible.” The acting Chief Executive and Registrar at the CMS, Mr Daniel Lehutjo, said in his statement that “members should resist the urge to spend all their benefits in the first couple of months” and “not to use your benefits to buy sunglasses, multivitamins or other lifestyle items over the counter.” All South African medical aids run financial years concurrent with the calendar year. This means that all the benefits (with the exception of oncology), limits and savings accounts are “renewed” on 1 January each year. When the New Year comes around a bulk lump sum of money is allocated to every member’s medical aid savings accounts and this sum is the accumulation of the next twelve, savings allocation portions, of the monthly premiums. “The lump sum of advanced annual savings needs to last until the end of December, and any non-essential items purchased now may unnecessarily increase any self-payment gaps which may require attention later in the year, once your savings are exhausted,” continues Larkan. Some additional tips from Larkan and the CMS which would help to extend members’ medical aid savings include: • Check if your medical aid has a formulary list of medications and if they do have one, request that your doctor, as far as possible, only dispenses listed medicines. A formulary is a list of prescribed medications – both generic and branded, for which your medical aid scheme will pay. The formulary helps to guide you to the most cost-effective medications that are effective for treating a particular condition. • If your scheme offers preventative screening tests, paid for by the scheme, get a list of these, and have as many done as possible, ensuring that any potential health issues are detected and addressed as early as possible. • If you take chronic medication, check that you are registered as a chronic medication member with your scheme, ensuring that as much of your monthly costs as possible are covered, by your scheme. If there is a Chronic Management program for your ailment, register for this and follow the program to improve, monitor and maintain your health. • Ensure that you know whether there is a designated service provider stipulated by your medical aid which you are required to use for various medical procedures. These service providers may include pharmacies, hospitals, doctors, specialists and even optometrist networks. Ensuring the designated service providers are used will help to curb additional expenses which service providers not in the network/s may be charging. • Obtain procedure codes and confirm authorisation and cover levels provided by your scheme. Understand what your portion of payment will be. Discuss these rates/tariffs with your doctor and negotiate these wherever possible. “By incorporating as many of these strategies as possible, members will be well on their way to maximising valuable medical aid savings. Professional advice from experienced medical aid consultants and advisors should be sought – whether through one’s employer or in a personal capacity – to ensure the retention of as much of your savings as possible,” Larkan concludes. To find out more on what your savings are from our different medical scheme providers please contact Namhla or Judy in our Health and Wellness Department, email health@daberistic.com, tel (011)658-1333 Source: FANews Three large open medical schemes have announced an average contribution increase of close to 10 percent or above for next year, following similar increases by four large open schemes in last week But members of three open schemes have been spared high increases: their medical schemes have announced average increases of between 5.4 and 7.5 percent.
Few weeks ago, Fedhealth announced an overall weighted average increase of 9.9 percent for next year across all options, with option increases ranging from minus 7.5 percent to 14.5 percent. Alexander Forbes Healthcare reports that Medshield has announced an average increase of 9.6 percent and Topmed has announced an 11.3-percent average increase, with its option increases ranging from nine to 13 percent. Three other large open schemes have announced lower increases: Sizwe will increase its contributions by an average of 7.5 percent, Genesis Medical Scheme by 5.5 percent, and Hosmed by 5.4 percent, according to the healthcare brokerage. The increases on Sizwe options range from 3.94 percent to 9.8 percent, Hosmed’s range from 3.3 percent to eight percent, and the Genesis option increases are from 3.6 percent to 6.8 percent, Alexander Forbes reports. The brokerage also records the average increase for next year on the restricted scheme for local authority employees, LAHealth, as six percent, with option increases ranging from 5.5 percent to nine percent. Genesis maintains its trend of having increases well below the overall scheme average. The scheme says it has also made significant enhancements to dentistry, external prosthetic and endoscopy benefits. Genesis chief executive Brian Watson says that about one-third of households with medical scheme cover spend more than 10 percent of their monthly income on medical scheme contributions. He says the debilitating effects of the continual above-inflation increases, as measured against the Consumer Price Index, often result in members downgrading their level of health cover or abandoning it altogether. Watson says Genesis has maintained low increases because it is one of the few open medical schemes in South Africa that is self-administered. It practises prudent risk management and fiscal discipline, he says. Fedhealth has announced that, over the next three years, it will simplify its options. Jeremy Yatt, the principal officer of Fedhealth, says the scheme will, at the end of three years, have an option range that shows a natural progression from in-hospital cover for a prescribed minimum benefit level of care only, up to unlimited cover and a choice of the level of day-to-day funding in line with members’ needs. This year, Fedhealth began to phase out its out-of-hospital expense benefit, which is paid from the risk pool. Yatt says none of the 10 largest open medical schemes other than Fedhealth pays day-to-day benefits from a risk pool; they all offer day-to-day cover from medical savings accounts, with some options having an above-threshold benefit that comes into effect when the savings account is exhausted. Yatt says Fedhealth will replace the out-of-hospital expense benefit with enhanced savings levels, which means that members will have more day-to-day spending than they currently enjoy with a out-of-hospital expense benefit/medical savings account combination. A great benefit of the savings account is that any unused balance at the end of the year carries over to the following year, while the out-of-hospital expense benefit did not carry over. Fedhealth has also simplified in-hospital co-payments across its options and has introduced a loyalty programme in partnership with Sanlam: Sanlam Reality. Other medical schemes that have announced contribution increases for next year to date are:
Remember that you should not make too much of comparisons between the percentage increases on different schemes, as the base contributions to which the increases are applied vary widely across schemes and options, as do the benefits and the increases in benefits for next year. Written by Laura du Preez |
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