Choosing the right medical aid cover

Choosing the right medical aid cover for you and yourfamily is very important. There are many options to choosefrom and before you make a decision, you may need to askyourself a few questions.How much can you afford to spend?When deciding to join a medical aid fund, first ask yourselfwhat you can afford to spend on the monthly premiums. If youneed to see a dentist, you’ll want a policy that pays for it. If youneed an operation you’ll want to be booked into a private wardin the best hospital in Namibia. But are you willing to spendN$10,000 per month for such a benefit privilege? If your budgetis between N$1,000 and N$1,500 a month, it is always best tochoose a benefits option that is affordable. Knowing how muchyou can spend reduces most of the work.What medical cover do you need?Medical aid cover is broken down into two parts:&bull; In-hospital expenses (which happen while admitted into a&bull; hospital) and&bull; Out-of-hospital-expenses (doctors, dentists and over the&bull; counter medication).Without knowing what you need from medical aid cover,you will not know which medical aid benefit option to choose.Therefore you will need to ask yourself the following questions:How much did you spend on day-to-day medical expensesduring the past year?How much did you spend on visits to the doctor – N$3,000?Hospitalisation – N$0? Dentistry – N$5,000? Medicine –N$2,000? If you already belong to a medical aid fund, it’s eveneasier. Just ask them to send you a copy of your claims historyfor the last twelve months;Which of those expenses where once off and which won’tcome up again soon (like maternity)? Which are likely to comeup again and again (Like the flu)? Twice a year you should seethe oral hygienist, so this needs to be included in the budget.Can you pay on your own out-of-hospital expenses?If yes, then look at medical aid fund options that just coversyour hospital requirements;If you don’t have enough money, then consider a medicalaid benefit option with a savings account (MSA) attached to it.More information can be found by reading the out-of-hospitalcover section of this article.If you find that you do not use the medical aid as much andis unlikely to claim unless you need a serious operation, thenall you need is a simple hospital benefit option. If you run outof savings by March, then you need a plan with much highersavings. For example, a 20 year old who hasn’t seen a doctorsince the day his mother gave birth to him needs somethingquite different from the 50 year old with high blood pressureand diabetes.The younger you are, generally, the healthier you are. Thatmeans you may need less coverage. The older and sicker youare, the more medical aid cover you need.Membership and reserve levelAccumulated funds (reserves) is the net asset value of medicalaid funds, and must be maintained at the minimum prudentialrequired reserve level (“reserves level”), i.e. 25% of grosscontributions. It is very important to look at the medical aidfund’s membership status and reserve level. Some funds have abig membership base, but their reserve level is far below or closeto the prudential minimum required level of 25%. This meansthe fund is likely to have a bigger premium increase at the end ofthe year. Reserve levels may drop annually, should a fund have abad claims experience that year.Other funds’ membership might be small, but the reserve levelis high, which means enough funds are available and premiumincreases at the end of the year can be expected to be lower thanthe average in the market.AdministrationIt is important to know who the Fund Administrator is and how efficient they are in offering assistance, client services andpaying out claims.In-hospital benefits, exclusions and co-paymentsBefore deciding on which medical aid fund benefit optionyou want to join, you have to look at the cover each one offersyou. The most important question is, how are you covered inhospital?Most medical aid funds benefit options cover you at 100%or more of the Namibian Association of Medical Aid Funds(NAMAF) tariffs. Other options cover you at 120%, 150%,200% or even 225%. This means it is always vital to negotiaterates with the medical provider (anaesthetist, specialist, doctor,etc.) If you don’t do that, you will be liable for the difference incosts. The other option is to take out an additional product tocover that cost, like additional insurance cover.ALWAYS read the small print. Study your product brochureto make sure of what is excluded on your option. Some medicalaid funds will exclude joint replacements or neck and backoperations, so it is VERY important to take note of exclusions.You will then know exactly what you are covered for and whatis not included in your package, so that you are not caught offguard.It is also important to be aware of all co-payments. Manymedical aid funds have co-payments (i.e. covered from yourpocket) on certain procedures, like gastroscopies, laparoscopies,removal of wisdom teeth, colonoscopies and joint replacements.Co-payments differ from fund to fund and also depend onwhether the procedure is done in or out of hospital.Out-of-hospital coverSome medical aid fund benefit options in the marketplacework with “savings”. These are called New Generation options,where you are given a percentage of your monthly premiumupfront for the year. This is available to you immediately,depending on the applicable waiting period.These “savings” will be used for almost everything outsideof hospitalisation and also for any co-payment you might have.Once the savings have been depleted for the year, you will haveto pay for the out-of-hospital expenses out of your own pocket.Chronic medicationWhen it comes to chronic medication, first make sure itis covered on the option you want to join. Ensure that yourcondition is regarded as chronic and that the medication youuse is also covered. Most people join an option because it coverstheir condition, but when it comes to the medication, the medicalaid fund says it is not on their formulary and is not covered. Theywill then request you to use an alternative. If that is not possible,they will pay you the Namibian dollar amount for the alternativeand you will be liable for the difference in cost.Oncology, dialysis and HIVYou also have to make sure how the medical aid fund andoption cover oncology, dialysis and HIV. Most medical aid fundshave specific benefit programmes for these conditions, whichoffer good cover, but it is important to make sure exactly whatthat cover is. - www.namfisa.com.naDid you know?No coverAll medical aid funds have a list of treatments, medicines and procedures that they will not cover.Health tipMedical insurance comes at a substantially lower cost than medical aid.Health precaution tipConsider your family’s medical history when making this decision.STATSAdvantages of medical aid:&bull;Financial protection if you suddenly have to pay large, unexpected medical costs.*No delay in your medical treatment.&bull;Better medical care because you are treated by private doctors, specialists and hospitals.

Choosing the right medical aid cover

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Namibian Sun 2024-11-19

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Choosing the right medical aid cover

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Namibian Sun 2024-11-19

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