Knowing your health plan cover well and being network-savvy can help you make the most of your health benefits. So, take a little time to know your cover. You may be surprised to see how convenient it is to use networks and the extra value you get.
Your choice of cover can mean you need to use networks
Having a health plan that recommends the use of networks can affect your day-to-day benefits and the medical aid cover you have at certain healthcare providers. Your health plan can require you to make use of specific hospitals, pharmacies, doctors or specialists in a network. It is all to your benefit. Using networks makes it possible for medical schemes to have arrangements in place that allow a lower contribution for those who use the network. This is great, since it means that your medical scheme can offer you full cover in these networks, without unexpected costs as long as you have benefits available.
It makes sense to take advantage of networks whenever you can
Using a network will be more convenient and by tapping into network arrangements, you can cut down on unexpected co-payments. So, not only would this keep your healthcare costs down, but usually, the medical scheme will also pay healthcare professionals within their network directly. These healthcare providers know the network arrangements well. This means you will not have any extra administration and your medical scheme can let you know when any extra costs are already included in their agreement with the healthcare provider.
Ways you can save by being network-savvy
1. At GPs
Some doctors charge more than the tariff specified by your medical scheme. This is something they have a right to do, but it means that if your health plan only covers you for the specified tariff, you may have to make a co-payment.
It can be embarrassing to discuss money with your healthcare provider, but when you make an appointment, you are entitled to ask what rates your doctor charges and whether or not you will have any co-payments. Discussing the costs upfront, means you can make informed decisions about how you are spending the funds you have available for day-to-day care. If you're set on that specific provider and you are happy to pay more, at least you'll know upfront exactly how much you need to pay.
"However," suggests Deon Kotzé, Head of Discovery Health, Vitality and Discovery Card Technical Marketing, "if affordability is a concern, shop around for a provider who is within the network and charges the agreed rate. These rates are usually the equivalent of the National Health Reference Price List rates. Discovery Health Medical Scheme, for example has an extensive GP network and, for lower income earners, the KeyCare GP network." Within these networks, the cost of consultations are paid in full and you do not have a co-payment as long as you have benefits available to cover the consultation.
2. At specialists
Visiting a specialist for the first time, they can ask you to pay for the first consultation upfront. When you have medical aid, you can send in this claim for a reimbursement. Before you visit a specialist, take a look at the information your medical scheme has available about specialists they have a payment arrangement with. Also, find out what your specialist will charge and whether or not they have an arrangement with your medical scheme to give you full cover and the benefit of direct payment when you need to submit claims. Nearly 90% of South Africa's specialists have a direct payment arrangement with Discovery Health Medical Scheme on most of its plans. When you see one of these specialists, you won't have any co-payments and the specialist will submit claims to the medical scheme directly, following the first consultation.
When you choose to see a specialist that is not part of a payment arrangement with your medical scheme, you may need to pay consultations upfront, pay a portion of the costs or submit these claims to your medical scheme yourself. Check with your medical scheme's call centre to find out what your options are. Don't be shy to discuss and agree on rates with your specialist. It can help you avoid extra costs and paperwork.
3. At pharmacies
Some medical schemes have pharmacy networks that offer no co-payment on medicines that are on the medical scheme's medicine list. For example, Discovery Health Medical Scheme has over 2 500 pharmacies in their network to choose from. When you use pharmacies that your medical scheme has an arrangement with, you get your medicine at the most affordable price and it offers you additional value. When you use the pharmacies in the network, you may also have access to additional medicine cover, depending on your health plan. Read about it here: Extra cover when you need it most.
It's always worth finding out whether or not your medical scheme offers you this service or access to a network of pharmacies so you can save as much on your medicine spend as possible. Another savings tip, is to ask your pharmacist about generic alternatives to branded medicines. Generic medicines cost less but are similar to the branded alternatives in their composition and how they work.
4. Day Surgery Networks
The Discovery Day Surgery Network provides national coverage for a range of medical procedures that can be performed on a same day basis. The network ensures national coverage by including both day surgery centre and acute hospitals. The Discovery Day Surgery Network will be subject to annual review. The list of network facilities will be made available in November 2018.
The Discovery Health Medical Scheme is an independent non-profit entity governed by the Medical Schemes Act, and regulated by the Council for Medical Schemes. It is administered by a separate company, Discovery Health (Pty) Ltd, an authorised financial services provider.
A large network to make your healthcare cover go further
Using network partners will make sure you are never charged more than the Discovery Health Rate. Check MaPS tool to find a GP in the large network or a specialist that has a payment arrangement on different health plans.
Also read more about the Day-to-day Extender Benefit that gives you full cover for day-to-day medical costs, like when you have spent your allocated yearly Medical Savings Account – and before you reach your Annual Threshold, if your plan has one.This benefit is available on plans with a Medical Savings Account (Executive, Comprehensive, Priority and Saver Plans) and is not available on Classic Comprehensive Zero MSA, Smart, Core and KeyCare plans.
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In the first, in a series of opinion-editorial published in Sunday Times and aimed at educating consumers about important matters in the South African healthcare sector, Dr Jonathan Broomberg, CEO of Discovery Health, delves into the key drivers of healthcare costs (Published: Sunday Times, 5 November 2017).
Discovery HomeCare is a unique service offered in the South African medical scheme market to provide patients with specific healthcare needs, access to high-quality care solutions at their homes.