The ins and out of upgrading and downgrading your medical aid plan

*The content is brought to you in partnership with Discovery Health Medical Scheme

By Deon Kotze*

  1. How will upgrading or downgrading your plan be of benefit to you?

medical_aidYou and your family have changing healthcare needs, and it is critical to ensure that your medical aid plan meets your family’s medical and financial needs, and also that you are comprehensively covered at all times. Downgrading your plan may result in some savings, but can also leave the family without adequate cover, particularly for an unanticipated medical event. Upgrading usually comes at a higher cost, but provides greater peace of mind that your family is fully covered for all possible medical needs.

  1. When can members upgrade or downgrade?

Members on the Discovery Health Medical Scheme can change (upgrade or downgrade) their plans with effect from 1 January each year. The deadline for submitting changes for 1 January 2017 is 15th December 2016. Members are able to downgrade anytime during the year. However, upgrades during the year are not allowed.

  1. How do I choose the “best” medical aid for me and my family – what do I need to lookout for?

Choosing a medical aid plan is both a financial and healthcare decision, thus a very important decision that requires careful consideration. It is important to consider things like:

  • Choice of providers: Some plans allow you to choose freely which doctor or to consult with and which hospital you would like to go to, while others place some restrictions on these choices in return for lower premiums. Discovery Health Medical Scheme has made use of its experience, expertise and scale to help keep private healthcare cover affordable by entering into arrangements with specialists and GPs which offer them a higher rate of reimbursement while ensuring you have limited co-payments. The arrangements benefits because it means when they use healthcare professionals who we have an arrangement with, we will cover their approved consultations and procedures in full.
  • Price: How much can you afford. Ideally, you should purchase the best possible cover that your family can afford. This will provide full peace of mind for an unexpected medical event, and is much better than purchasing a lower cost plan and then trying to upgrade later when such an event occurs.
  • How much cover: This is also related to age, health status and needs. Young, healthy people and people with no or few financial dependents typically could need less cover. If you’re older, in poor health or have a large family, you may need more comprehensive cover than that offered on a hospital option only.

A financial adviser can help with a full needs analysis to determine which plan will best suit your needs.

Read also: Discovery Health incentivizes doctors to get healthy for their own sake and that of their patients

  1. What do I need to know about my medical aid before I start “using” it – before I go to the doctor, dentist, optometrist, gynae, etc.?

You would need to understand the following:

  • Whether the healthcare provider is in a network of providers linked to your plan. This ensures that you go to a provider who charges what is already negotiated with your medical scheme, thus reducing potential co-payments.
  • If you are on a plan that has a medical savings account, check the balance you are given for the entire year and gauge if this will be enough to cover your day-to-day benefits for the year.
  • If you are on a plan where the medical scheme pays for the day-to-day expenses, check the limit you and your family have against how much is already used that year.
  1. What about generic medicines? Is this advisable and do medical aids actually want their clients to ask for generic?

Where generics are available, they are a perfectly acceptable substitute for brand name medicines, unless your doctor has explicitly ruled out the use of a generic. Over 80% of Discovery Health Medical Scheme members use generic alternatives, which eliminates the need for any copayments or levies on their medicine.

  • Deon Kotze, Head of Research & Development, Discovery Health
  • The Discovery Health Medical Scheme offers the widest choice of health plans, all with unlimited private hospital cover and a range of benefits to suit your needs and your pocket. Visit www.discovery.co.za to find out more and get a quote in 60 seconds. 
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