As you begin 2024 with a clean slate in terms of medical aid benefits, it’s a good time to look at ways to manage medical expenses.

Here are 10 tips to empower yourself in managing medical expenses.

1. Designated Service Providers (DSPs) and networks

Healthcare costs in South Africa are generally unregulated which means providers are free to charge any tariff.

Using DSPs and hospital networks means that favourable tariffs for members have been negotiated.  Using networks also means you can reduce or eliminate co-payments.

2. Tariffs and rates of payments

The Scheme Rate is the amount a scheme will pay for specific treatments and procedures. However, 100% of the scheme rate doesn’t necessarily mean 100% of the account will be paid.

Ask for a quote from your practitioner and/or hospital ahead of any procedure. If there is a major discrepancy, try and negotiate an adjusted fee.

3. The value-add benefits

Make use of the free wellness screening and testing offered by your medical aid.

There has been an intensified drive to detect, prevent or manage various chronic conditions as well as vaccinate against potential diseases and conditions.

After completing an online wellness questionnaire or a wellness screening, many Medical Aids offer some kind of a reward. It’s about being on the right path to good health and wellness.

HPV vaccines, stool tests for colon cancer, dental fissure sealants, online hearing screenings and contraceptives.

4. Ask your pharmacists

Ask your pharmacists for over-the-counter medications for less serious illnesses.

Pharmacists are able to provide sound medical advice about problems like rashes, colds or illnesses that are not severe.

Also use generic medications where possible. A generic’s active ingredient or drug content is identical but is between 30% and 80% cheaper.

5. Managed Care

The prevalence of Non-Communicable Diseases (NCDs) has been increasing year-on-year, so have mental health issues, which is a risk factor for NCDs and vice versa.

For this reason, it is important to make full use the Care programmes your medical aid offers.

6. Remember to pre-authorise

Pre-authorisation is required for all hospital admissions, out-of-hospital screenings and procedures.

Always ask if there are any co-payments or sub-limits that will apply and how to avoid these.

For planned procedures, make sure you use a DSP or check whether the procedure can be in the doctor’s rooms or a day clinic.

7. Be aware of consulting after hours

Be careful about using after-hours consultations or emergency rooms unless it’s absolutely necessary. In a bona fide medical emergency, one has no choice and this usually results in admission to hospital.

8. Manage your chronic medicine correctly

The golden rule for chronic illness benefits is to try to use the medication on the scheme’s formulary and to obtain this from a specified pharmacy, either on the network or a DSP.

9. PMBs

Make sure you understand what is covered under Prescribed Minimum Benefits (PMBs) and to use a DSP to ensure that claims are paid from risk, not from your medical savings account.

10. Gap Cover

Gap Cover is designed to cover the difference or part of the difference between what the medical scheme pays and the service provider charges for in-hospital procedures/treatment and specified outpatient procedures.

Ensuring you ‘work smarter’ with the benefits and medical expenses during the year, is a win-win situation for your health and pocket.


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