While many South Africans have begun their preparations for the festive season, there is another pressing priority that requires attention before the year draws to a close. “There are a number of factors to take into account when choosing a medical scheme option that will best suit a family’s needs for the following year,” notes Bianca Viljoen, spokeswoman for Health Squared Medical Scheme.

Health Squared’s Advance, Optimum and Cobalt options are highly flexible, because the structure allows for members’ access out-of-hospital benefits from both a PMSA, as well as traditional benefits for allocated healthcare services.

In most cases, it is only possible for members to change to their benefit option once a year with the relevant paperwork needing to be submitted in advance – usually in early December.

“Of course, it is not possible to predict, with absolute certainty at least, what an individual or family’s healthcare needs will look like in the following year. However, it is still highly recommended that you give it some thought and consider a few basic questions as a starting point.

“For example, are you planning on starting a family soon, or were you or a dependent recently diagnosed with a chronic condition? The best course of action is to speak to an accredited healthcare broker who is able to expertly assess your unique healthcare needs and match these to the most suitable option,” Viljoen recommends.

A basic understanding of the various benefit structures available is also useful for medical scheme members when reviewing their options for the year ahead. “The three main types of benefit structure are traditional, new generation or hybrid options, with each offering their own advantages depending on the member’s priorities,” she notes.

“Members can therefore enjoy greater control over their benefits and healthcare spend by choosing from options within the benefit structure that is most suitable to their unique requirements.”

Traditional benefit options offer members structured access to healthcare with a capped Rand value across various categories of out-of-hospital services, and unlimited access to in-hospital care at private hospitals. It is important to note that benefits are allocated annually and unused benefits cannot be carried over to the following year.

“Traditional options offer great security and exceptional Rand value. These options allow members to claim for each category of healthcare without impacting their entitlement to the other categories of healthcare available on their chosen benefit option. With Health Squared, examples of this benefit structure include benefit options such as Ultimate, Flex, Flex Plus and Foundation.

New generation options provide the security of structured access to in- and out-of-hospital benefits and a personal medical savings account (PMSA) portion. The PMSA is separate from the scheme’s risk pool and can only be accessed by the member.

Health Squared’s Millennium option, for example, is a new generation option, where families can enjoy the flexibility of a generous PMSA account as well as additional peace of mind with an Above Threshold Benefit (ATB)to cover the family’s day-to-day healthcare needs.

“The Millennium option is ideal for larger families, as they only pay for their first two child dependents, with third and subsequent children covered at no additional cost. More established individuals and ‘empty nesters’ appreciate the unlimited access to oncology benefits, as well as cover for 59 chronic conditions and advanced dentistry cover available on this option.”

While the structured benefits are granted on an annual basis, as is the case with traditional benefit options, any remaining savings in the PMSA component of such plans are accrued year-on-year.

Hybrid benefit options offer the security of comprehensive structured in-hospital cover combined with greater freedom when it comes to day-to-day healthcare cover.

Health Squared’s Advance, Optimum and Cobalt options are highly flexible, because the structure allows for members’ access out-of-hospital benefits from both a PMSA, as well as traditional benefits for allocated healthcare services. It therefore provides access to “the best of both worlds” in combining savings, as well as traditional benefits for day-to-day healthcare requirements.

“With this degree of flexibility, members can access the benefits that are most relevant to their needs and save any surplus PMSA funds for the following year,” Viljoen says.

“Remember, it is crucial that all members familiarise themselves with what exactly their chosen option for the year ahead provides cover for, and whether they are required to make use of designated service providers when accessing healthcare.

“This is the ideal time to switch to Health Squared, which offers healthcare cover options designed to suit individuals and families’ health needs and their budget.

“Some medical scheme members may be hesitant to leave their current medical scheme on the basis that they concerned about losing their accumulated PMSA funds. However, such individuals should be aware that on resigning from their present medical scheme, the funds must either be transferred to their new scheme, if they opt for a new generation or hybrid option, or if they sign up to a traditional option these funds must be paid out to the member.”

“The range of choice available through the various benefit structures offered by Health Squared makes it possible for members to have greater control over how their medical scheme funds are allocated, and secure benefits that offer the best possible value proposition for their needs,” Viljoen concludes.