Ina Opperman

By Ina Opperman

Business Journalist

Can’t afford medical scheme membership? Here are some alternative options

Nobody wants to end up in a state hospital, but will health insurance help to give you access to private health care?

If you cannot afford medical scheme membership, there are some options to consider to ensure that you still have access to private health care, such as health insurance.

Out-of-pocket health costs can seriously affect your budget if you have no cover.

Health insurance is an option because it provides a range of options for cover from basic primary care only options for your day-to-day needs, as well as hospital only options and more comprehensive care combining in and out of hospital benefits. 

According to Chris Pretorius, chief underwriting and claims officer of GENRIC Insurance, underwriters of Wesmart Financial and Administration Solutions, health insurance helps people who have no option but to opt out of medical scheme membership because they cannot afford it anymore, as well as those who simply have no access to traditional healthcare funding options.

“Demand for basic health insurance plans that cover basic primary medical care, such as day-to-day consultations with general practitioners, dentistry, optometry and acute and chronic medication grew significantly in the last 12 months as the state of public healthcare facilities declined, with interest in more comprehensive plans also increasing.”

ALSO READ: SA scores 45th out of 60 countries for cost of healthcare

Why is health insurance cheaper than medical scheme membership?

Pretorius says medical scheme membership is more expensive because medical schemes must provide full cover for a list of treatments and conditions called Prescribed Minimum Benefits (PMBs) that include 270 in-hospital, life-threatening procedures and 26 listed chronic conditions, which must be covered at cost for all members.

“Members pay for these benefits, whether they use them or not, and many members may never even need to claim for a PMB event in their lifetime. This ‘base’ cost for PMBs typically puts medical scheme access out of reach for most lower to middle income earners.”

Health insurance, on the other hand, does not cover PMBs and can specify its benefits with a defined or fixed amount, from a doctor’s visit, to medication, to a hospital procedure, emergency, or accident, up to a fixed sum defined in the policy.

“This means you do not have the hard upfront cost for a set of PMBs that you may never actually end up using or needing. From an employer’s perspective, health insurance means that you can build your employee health benefits strategy based on the employee’s actual needs, as well as on what the company and employee can afford,” Pretorius says.   

The cost of even an entry level, basic private medical scheme benefit, which on average starts at around R1 300 per month for a main member, is typically out of reach for millions of workers and for SMEs that want to provide these benefits for their staff but simply cannot afford to.

Pretorius says health insurance also works with a designated list of private healthcare providers that you must use, which helps to keep the cost of cover more affordable. You can also use health insurance in conjunction with your medical aid scheme to cover any possible shortfalls that may be incurred.

You can, for example, be on a core hospital plan with a medical scheme and use your primary care health insurance benefit to cover your day-to-day, out-of-hospital healthcare needs.

“Medical schemes often have shortfalls due to the difference between the medical scheme rate and the rate health care providers charge. Members often take out additional gap insurance to cover these shortfalls.”

Another difference is that health insurance pays benefits according to a policy schedule, while medical schemes are tariff and protocol driven.

ALSO READ: It’s medical aid scheme renewal season – here’s how to make the right choices

Preventative care

“A significant benefit is that certain health insurance benefit options also provide for preventative care which is a big advantage of being covered. Most people without health insurance postpone going for annual check-ups or health screenings, if at all,” Pretorius says.

Having access to preventative care helps doctors detect an illness early and early detection can minimise the severity of an illness and possibly even save your life. More comprehensive health insurance options provide extra peace of mind by providing access to 24-hour emergency medical services and ICU benefits.

“Health insurance gives consumers access to quality private healthcare quickly and affordably, ensuring that a health event does not become a financial crisis as well.

“Whether you are an individual looking for a cost-effective solution that understands that you are healthy and do not need all the bells and whistles, a family that needs an affordable solution that meets your growing needs or an employer that needs a viable healthcare solution for employees to take care of day-to-day doctor visits and medication, health insurance provides an invaluable solution where medical scheme benefits are simply not affordable.”

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