What to Look for When Comparing Medical Aids (2024)

When comparing medical aid schemes, choosing one should be a well-thought-out decision.

It needs careful consideration because you and your family are relying on it financially to get you through when your health fails you or you have an accident.

We’re sharing some tips for comparing medical aids so you can make the best possible decision when it comes to medical aid providers. Let's do this!

What Kind of Cover Do You Want?

The first thing to decide is what type of cover you need. There are two main types of medical aid cover available in South Africa. These are:

• Hospital plans: Cover only for in-hospital expenses. Some have very limited out-of-hospital benefits, but not all.
• Comprehensive plans: This offers everything a hospital plan does as well as out-of-hospital cover for doctor visits, medications, and other medical expenses. Some feature a medical savings account (MSA) for you to use on additional day-to-day expenses.

If you’re in good health, then it might only be necessary to have a hospital plan in case of emergencies or the need arises for an operation.

If you have a large family where doctor visits are frequent, or if you’re an older individual with more medical needs, a comprehensive plan will offer more cover. It’s all about weighing up your medical needs with what you can afford.

When choosing a low-cost medical aid option, consider the possible in-hospital exclusions and limitations, and how this will affect you.

What Are the Benefits?

The next thing to consider are the additional benefits that come with your medical aid plan. Medical schemes often include benefits for maternity, for example. But they're not all created equal.

Some will have cover that will run out three months into your pregnancy (yikes!), while others might pay for up to 12 consultations, which would just about see you through to the birth.

If you know you need a benefit like this, or say, an MRI scan for your back periodically, look for a medical aid plan that will give you the most cover.

Which Doctors and Facilities Are on the Designated Service Provider List?

The designated service provider (DSP) list applies to medical aid plans that stipulate that you use a specific network of providers. This is a list of professionals and facilities that you can visit. If you visit someone not on this list, then you'll most likely need to make a co-payment. This can be a standard figure or a percentage of the total medical bill.

Though you’re restricted to the medical provider you use, network plans tend to have lower premiums – so it’s important to weigh up the pros and cons.

Look at the Sub-Limits

Sub-limits are the amounts that medical aids will cover for specific treatments or procedures. This applies to diseases like cancer or some operations, where the medical scheme will either pay a set amount per year, or have a limit per incident, or both.

An example would be a mammogram. The scheme might pay for one mammogram every two years for women over the age of 40. They'll cover a set amount for the mammogram. If the test costs more than this, the outstanding amount is for you to pay.

Examine the Co-Payments

Whether you're on a network plan or not, certain procedures and treatments will require you to make a co-payment. For example, getting a CT scan might result in the medical aid paying 60%, and you need to pay the remaining 40%. If you've got an injury that requires you to get scans every so often, it's a good idea to look at the medical aid scheme's co-payments.

How Much Cover Will the Medical Aid Provide?

Medical care can be expensive, especially when it comes to in-hospital procedures. There's no way the average South African can afford care at a private hospital in SA without the help of a medical aid.

But what happens if your medical aid covers up to 100% of their own rate, and the specialist you saw charges 400% of that rate? You could be in financial trouble if you don't have thousands of rands lying around. Make sure that you can deal with the shortfall between the medical aid rate and the specialist's tariff.

Go For Gap Cover

Gap cover is an amazing healthcare solution that's changed the way people approach medical aid. No matter what type of cover you get—hospital, savings, or comprehensive—we suggest you take out gap cover. It covers the shortfall between the medical aid tariff and the specialist's tariff when you have an in-hospital procedure.

Some of them even cover certain out-of-hospital procedures, like MRIs and CAT scans.

Look at the Solvency Ratio

You might be wondering what in the world we're talking about, but the solvency ratio of a medical aid is really important.

It refers to a legal requirement that medical aids have to put aside accumulated funds of at least 25% of the total annual contributions from its members. Think of it like a safety net, there to give you peace of mind as a member. The higher the solvency ratio is, the more money the scheme is maintaining, which typically means it's in a better financial position.

Now that you've taken our guided tour through what to look for when comparing medical aids, it's time to get started with it! Start your medical aid quote comparison today.