How to get good value from your medical scheme

Andre Jacobs | 06 December 2022

Andre Jacobs is the marketing manager for The People Company, an employee benefits consultancy, and the author of the book Medical Schemes Explained: Your ultimate guide to using your medical scheme efficiently

It is possible that two members who have the same disease profile can belong to the same medical scheme option and have vastly different experiences.

One member, let’s call her Mary, thinks her medical scheme is fantastic as it covers all her medical expenses and she even carries some of her savings over to the next year.

The other member, Jackson, is very upset with his medical scheme. He depletes his savings account in April each year. He stays in the self-payment gap, and it gets bigger during the year.

He thinks the medical scheme is run by a bunch of crooks.

How is it possible that two people on the same medical scheme option can have such different experiences? 

The answer is that Mary knows how her scheme works and uses it efficiently while Jackson does not.

Jackson could also find value for money in the option if he found out a bit more about the scheme’s benefits and used the scheme more efficiently.

Here are eight ways in which you may find more value in your medical scheme.


Tip 1: Register your chronic condition

If you are diagnosed with a chronic condition, you need to do the following:

  • Register the chronic condition.
  • Where applicable, register on the relevant managed care programme.
  • Obtain a copy of the formulary (list of medicines), and the treatment protocol (treatment plan) and discuss it with your doctor. This will ensure that the doctor prescribes medicine and follows the correct treatment plan, that will be paid by the medical scheme and you will avoid co-payments.
  • Read up and be informed about your condition. Your doctor will be able to direct you to the most appropriate evidence-based articles.
  • Listen to the advice regarding your lifestyle that your doctor will give you. More than 80% of the costs associated with chronic conditions are driven by lifestyle choices.

Tip 2: Use your scheme’s designated service provider

Find out whether your medical scheme has named a designated service provider (DSP) for the treatment of your condition and make sure that you use it. This will prevent you being liable for co-payments.

If you use a provider that is not a DSP, you may not be covered or only partially covered.

Schemes change their DSPs frequently.  These can be obtained from the medical scheme or from the medical scheme app. Read more: What is a prescribed minimum benefit?

Tip 3: Be open to generic substitution

Try to obtain generic medicine instead of original or patented medication, as it is cheaper, and the medical scheme will usually pay for generic medication in full (subject to availability of savings and/or sub limits).

If you really need the original medication, you may have to pay a co-payment (levy) of the difference between the price of the original medication, and that of the generic. Ask your doctor to prescribe generic medication and add your wish to your medical file. You can also discuss the suitability of generic substitution with your pharmacist.

Tip 4: Know the reimbursement rate

Make sure you understand the reimbursement rate for providers that is applicable to your chosen option and check with healthcare providers what they charge. Ensure that the provider is aware of this reimbursement rate and negotiate with them to charge that rate.

Remember that both your doctor and medical service provider are obliged, in terms of the National Health Act, to disclose the costs to you before medical services are rendered. However, nothing stops you from requesting this information well before.

Tip 5: Pay claims from your savings account at scheme rates

Some medical schemes allow you to choose how you want claims paid from your medical savings account. You can either be reimbursed for the full cost a provider charges you or you can be reimbursed for the treatment at the medical scheme rates. You should rather choose the medical scheme rate as this will ensure that you negotiate rates with your doctor or other providers and that you preserve your medical savings account for longer.  Read more: Why does my medical savings account run out before the end of the year? and What is an above-threshold benefit on my medical scheme?

Tip 6: Don’t spend your savings on vitamins

Do not use your medical savings account to purchase over-the-counter (OTC) medication (Schedule 0, 1 or 2 drugs), vitamins, and supplements. This will deplete your savings and, if you enjoy an above-threshold benefit on your option, it will increase your self-payment gap.

Tip 7: Prevention is better than cure

Prevention is better than cure.  This is why we service cars and maintain buildings. The same applies to our health. We know that managing stress, not smoking, sleeping enough, eating the right food and being active can prevent diseases.

Doing these things costs less than treating the diseases associated with not doing them.

Most medical schemes have preventative benefits, such as pap smears, mammograms, or prostate checks. These tests improve the chances of your illness being properly managed or even cured, if detected early. Some medical schemes provide additional day-to-day benefits if specific tests or health checks are done. Research has shown that for every R1 spent on prevention, more than R10 is saved. It is an excellent investment to invest in your health.


Tip 8: Select your broker carefully

Check your broker’s accreditation and his or her level of expertise. Also ensure that the broker is independent. Avoid measuring a broker’s independence by the number of contracts, but rather consider his or her independence of thought. If the broker keeps referring to one medical scheme, or its value-added benefits, the broker may not be as independent as you thought. Read more: How can I get advice on my healthcare cover?