AUTHOR: Victor Crouser, Coastal head of Healthcare for Alexander Forbes
Most medical schemes announce their changes for the following calendar year from September onwards. The changes normally come into effect on 1 January and towards the end of the year is when members must re-evaluate their cover and determine if they are on the most appropriate scheme and option for their healthcare needs. A good healthcare adviser can assist with these decisions – normally receiving a commission from the scheme so members are effectively already paying for this.
With medical schemes becoming more complex, many people do not realise what benefits they have actually bought and are horrified during the course of the year to realise they do not have enough cover. While one can never truly predict your future health, a good healthcare adviser will help in assessing past and present usage and determine anticipated future needs. A healthcare adviser should then guide the member to the most appropriate option within their chosen medical scheme while simplifying the complicated terminology and scheme processes. If the selected medical scheme is no longer suitable, then the adviser will help select a more appropriate scheme in the marketplace.
Many options require members to only use particular network providers in order to access benefits. For the average person, this can be difficult to understand. Failure to do so could also result in shortfalls and co-payments. The healthcare adviser should explain exactly how the networks work and the consequences of not using these.
In addition, the healthcare adviser should guide members to maximise utilisation of the available benefits. As an example, a member may be taking chronic medication, but forget to register on the medical schemes chronic programme, meaning that the medication is paid for from savings or day-to-day benefits, rather than fully covered by the medical scheme. In addition, by registering on the chronic programme, members may have access to additional benefits such as doctor consultations.
A qualified healthcare adviser should also help members to understand exactly what they can and cannot claim for. Often when using the scheme call centres, members are still unsure if what they have been told is correct. Members should check with their healthcare adviser who should have in-depth knowledge of the Medical Schemes Act, as well as the processes and procedures followed within the medical scheme. This will ensure that the adviser is in a position to ensure that a member’s claims are properly processed and paid. This is particularly relevant, when it comes to claims for Prescribed Minimum Benefits (PMBs). Legally schemes are obliged to pay for these, within certain guidelines, but often due to administrative issues, such as the use of incorrect codes, the schemes will reject payment. PMBs cover all medical emergencies, almost 300 life-threatening conditions and 25 common chronic conditions.
A good healthcare adviser will understand and be able to advise you on the appropriateness of alternative healthcare solutions, such as gap cover, primary care, occupational health and healthcare insurance type products.
How to find a good healthcare adviser
Medical scheme advisers must be accredited with the Council for Medical Schemes before they can be paid a commission by a medical scheme. The council only accredits brokers who have a grade 12 education or an equivalent qualification and at least two years’ experience as a broker or apprentice broker in a healthcare business.
The council will not accredit an adviser if he or she is not fit to be one – for example, if he or she has been convicted of theft, fraud or any other offence involving dishonesty. A list of healthcare advisers is available on the Council for Medical Schemes website, and accreditation must be renewed every two years.