Pros and Cons of a Network Medical Aid

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What is a network medical aid option?

A network medical aid option requires that you use specific hospitals and/or doctors with whom the medical aid scheme has a specific payment arrangement.

How do network-based medical aid options work?

The medical aid companies usually contract with a group of hospitals and agree to pay a certain (lower than usual) fee, with the promise of sending more patients to them through the network options.

The medical aid’s arrangement with doctors is usually to pay a monthly rate to the GP per network-patient on his patient-base. Regardless of whether the member visits the doctor once, ten times or not at all, the amount will be paid monthly.

By these arrangements, the network-based medical aid scheme can offer you more affordable rates.

Members need to work through their GP, who is seen as the Gatekeeper, no matter what is wrong with you.

For most, if not all medical services, you need to make use of specific providers in order to receive any payment from your scheme.

[tip title=”moneysmart tip”]When in doubt about what will be covered or not, contact your GP or medical aid scheme.[/tip]

A network option is different from other non-network options as you need to ensure you use the correct providers and that your condition or treatment is in fact covered as there are restrictive formularies and benefits.

On non-network options, you will usually have more extensive benefits without the same level of restrictions – at a higher price.

Comparison of network-based medical aid options

Let us look at a medical aid comparison of 4 different medical schemes, which are network options:

MEDICAL AID SCHEME / OPTION

DISCOVERY HEALTH
KEYCARE PLUS

MEDIHELP NECESSE

MOMENTUM
INGWE

RESOLUTION
FOUNDATION

PREMIUM

Starting at R638 (single) Starting at R828 (single) Starting at R496 (single) Starting at R566 (single)

CHRONIC MEDICINE

27 PMB* conditions

Unlimited subject to restrictive formulary

27 PMB* conditions

Unlimited subject to restrictive formulary

27 PMB* conditions

Unlimited subject to restrictive formulary

27 PMB* conditions

Unlimited subject to restrictive formulary

IN-HOSPITAL BENEFITS

100% Scheme Rate

No Annual Limit

Network Hospitals

100% Scheme Rate

No Annual Limit

Network Hospitals

100% Scheme Rate

R950k p/family per annum

Network Hospitals

100% Scheme Rate

Unlimited PMBs only

Network Hospitals

DAY-TO-DAY

BENEFITS

GP:

No limit using network doctor

Specialist:

R2550

Dentistry:

Basic at network dentist

Optometry:

2 yearly benefit

GP:

8 consultations p/family, pre-auth thereafter

Specialist:

R2240 single
R3180 p/family

Dentistry:

Basic at network dentist

Optometry:

2 yearly benefit

GP:

No limit using network doctor

Specialist:

2 visits per family- max R750 per event

Dentistry:

Basic at network dentist

Optometry:

2 yearly benefit

GP:

No limit using network doctor

Specialist:

Subject to PMBs and referrals

Dentistry:

R1500 single

R2500 p/family

Optometry:

yearly benefit

*PMBs are Prescribed Minimum Benefits. These are the minimum benefits which all medical schemes must provide to their members according to law.

Pros and cons of a network-based medical aid option

Network Medical aid Options are typically designed for younger people who have a limited medical aid budget and who are relatively healthy.

Why do we say that it is meant for younger people??

Most, if not all, network options exclude certain conditions that are typically “older people’s” conditions e.g. hip/knee replacements.

However, these conditions will be covered if as a result of an accident.

PROS

CONS

By choosing a network option you’re sure to pay reduced rates so if your income is very low, you should find this type of plan affordable. This type of scheme could cost more in the long run for an older person, in the event of a knee or hip replacement for example, where it will not be covered by the scheme AT ALL.

 

[tip title=”moneysmart tip”]Your medical aid plan is only as good as your knowledge of it! If you fully understand your benefits, you will be happy with your plan and not be caught off-guard by unpaid accounts.[/tip]

Get a Medical Aid Quote by Completing the Form Below

[gravityform id=”1″ name=”Medical Aid SA”]

PLEASE NOTE that the information herein is for illustrative purposes only and should not be regarded as advice. All information is subject to scheme rules which can change at any time without any prior notice.

If you require more details on these schemes or their products, please feel free to contact the schemes directly via their websites or call centres.

  • www.discovery.co.za or telephone (0860) 99 88 77
  • www.medihelp.co.za or telephone (0860) 100 678
  • www.momentumhealth.co.za or telephone: (0860) 117 859
  • www.resolutionhealth.co.zaor telephone (0861) 796 6400
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About Author

Nelda Celliers is a medical aid advisor based in Cape Town. She has a Higher Certificate in Insurance through the Insurance Institute of South Africa. Nelda obtained her licenses from the Financial Services Board and Council for Medical Schemes to operate her own medical aid practice, Medical Benefit Advisors.

  • David

    What is a good age to get medical aid?

    • Shana

      Hi David,
      In my opinion as soon as you can afford it! Anything can happen at any time, so be prepared.
      You will not drive without car insurance, so why not insure your heath?