Most medical aid schemes will tell you that they ensure the health of their members by paying for a list of preventive screening procedures. They pay for this from the risk portion of the scheme, yet many members are not aware of these benefits or the terms and conditions that go with them.
Certain health tests are paid for from the major benefits or the risk portion of your plan and not your day-to-day savings.
Even a member on a hospital plan would have some of these screenings paid for by the scheme. These can include screenings such as mammograms, bone density tests, routine dentist visits, pap smears, prostate checks and even contraceptives.
Last year, when I turned 50, my doctor recommended that I do a set of preventive screenings that included a mammogram and bone density test. I also went for my regular dental checkup, along with my children.
I assumed these were covered by the Momentum Health Platform benefits as they are all preventive screenings. Yet when my savings dried up quickly, I checked and discovered they had been paid from day-to-day savings.
What I had not realised is that Momentum requires a pre-approval before doing screening tests. Had I been informed of this, I would have saved more than R6 000.
It appears Momentum is one of the few schemes that requires pre-approval. Speaking to a number of brokers for large medical schemes, I learnt that several were unaware of this provision. However, many schemes have fine print you should be aware of.
Last year, Discovery announced its WELLTH Fund, a once-off bonus providing members with additional funds to provide for screening tests this year. But, again, one has to be aware of the terms and conditions.
Portia Mahlalela, regional executive at Alexander Forbes Health, says the medical schemes differ on what they cover. Some require you to use a designated service provider. For example, some schemes may require you to use Dis-Chem or Clicks for the screening tests such as cholesterol, blood pressure and body mass index.
“You will be surprised how much you can get from your medical scheme. Benefit guides are updated every year but members seldom read them.
“Schemes should do more to encourage screenings by providing regular, bite-sized information to educate members,” says Mahlalela. She adds that, to be on the safe side, before you do a series of tests, it is best to speak to your broker to find out what is covered by the risk or day-to-day benefits.
The lesson learnt is that it pays to fully understand your scheme’s benefits.
“It benefits you to fully understand the plan that you are on and to make sure you are making the most of the preventive screening benefits,” says Mahlalela.
Make sure you read the fine print, because some benefits differ between schemes and even between plans of the same schemes, for example, their frequency as well as what they actually cover. As Larkan points out, Discovery’s screening and prevention benefit only pays for the test and not the consultation. This will come from your day-to-day savings.
THIS IS WHAT YOU NEED TO CHECK:
Frequency: Some screenings may be available annually but others only every few years. Schemes differ on their frequency even between plans.
What is covered: Some schemes only pay for the cost of the tests while others include consultation.
Service provider: Some schemes require you to use designated service providers, others allow you to go to any provider.
Payment limits: There are limits on the amount the scheme will pay, so if the medical service provider charges a rate higher than the scheme’s rates, you may have a co-payment.
Pre-authorisation: Some schemes, such as Fedhealth, do not require pre-authorisation. Others, like Momentum Health, do require you to get authorisation first.
Unlocking additional benefits: Some schemes provide additional benefits if you complete a health assessment. For example, Bestmed, Bonitas and Discovery all provide additional cover if a health assessment is completed.
We did a comparison of preventive screening benefits of several medical schemes. Note that the frequency of screenings may depend on which plan you are on. This table serves only as an illustration of the type of benefits available.