Council for Medical Schemes (CMS), regulator of the medical schemes industry, advises medical scheme members to use their benefits wisely – especially at the beginning of the year – with the aim of making their benefits last longer.
The most common advice is to not use your benefits to buy sunglasses, multivitamins or other lifestyle items over the counter, but instead use it for essential medicines when the need arises. Members are also advised to ask their doctors to prescribe in formulary drugs (this is a list of drugs that will be funded by medical schemes for each condition).
A formulary regularly consist of generic medication, especially in higher schedule categories, which is generally cheaper and thereby save funds while it is just as effective as the more expensive alternative.
Members are encouraged to make use of the preventative screenings and tests which many schemes offer. Members should also seek to register on the relevant chronic management programmes if they have certain illnesses, thereby ensuring their condition is monitored and that they receive all the necessary care.
The following advice will assist members to determine if and how much they are likely to pay out of their own pockets:
- Contact your medical scheme and ask who the DSP (designated service provider) is for the service or product that you need.
- If you need to undergo an operation, ask your surgeon for the codes that will be charged. This will include the procedure codes and those for any other products that is needed, such as an internal prosthesis that will be used.
- Discuss the medical scheme tariff with your surgeon and if possible the anesthetist and negotiate the price that you will pay.
- Contact your medical scheme and ask whether the specific type of product will be funded in full. If not, make sure that you know what part of the cost will be for your own pocket.
- Ask your scheme to provide you with a list of DSPs for the product or procedure you need to undergo. The scheme may appoint a surgeon, hospital and anaesthetists as designated service providers. These providers usually have agreements with the schemes for non-PMBs as well.
- Determine if there is a shortfall and make plans how this will be funded.
- Obtain pre-authorisation for procedures as provided for in the rules of your medical scheme