THE ROLE OF THE BROKER IN THE HEALTHCARE ENVIRONMENT

Brokers provide many services to consumers that ensure that consumers can make informed decisions.  Essentially these services fall within two broad categories, i.e. to advise and protect the medical aid member. The services mentioned below are covered by the normal regulated commission fee on a monthly basis: • which medical scheme to select, • your rights when changing medical schemes, • the consequences of changing schemes, • the details and procedures applicable to the new scheme (education), • annual option changes • changes in legislation and the impact thereof, • changes to the benefit structures and/or the procedures applicable to the scheme and the impact thereof. • giving on-going feedback on the financial and administrative stability of their chosen scheme. An intermediary of Healthcare Consultant has a vital role in assessing the needs of a prospective member and structuring an appropriate plan for members of an employer group or an individual member.  There are a significant number of medical schemes to choose from, and each of these has a number of benefit options which complicates the selection process for a member without support of an informed and experienced professional. Mitzie Ginsburg  ...

HOW TO DECIDE WHETHER YOU WOULD WANT COMPULSORY MEMBERSHIP OF ONE MEDICAL AID OR OPEN THE CHOICE TO MORE THAN ONE MEDICAL AID

The main reasons given by executives when asked why their companies provide their employees with medical aid include:  To provide relevant employee benefits to attract and retain staff. To keep staff healthy and at work. To minimize the risk of a major financial loss for an individual       employee with inadequate cover. All medical schemes have a right to protect themselves against anti-selective behaviour and when an Employer allows staff to choose between more than one medical scheme the medical schemes will protect themselves against anti-selection by: Applying a general three month specific exclusion and a 12 month conditions specific exclusion for those employees who have not been on a medical aid in the last 90 days. Even if the break is less than 90 days they may apply the above waiting periods but in this case the member will be able to access treatments which are classified as Prescribed Minimum Benefits (PMBs) in terms of the Medical Schemes Act. Importantly for individuals over 35 applying for membership of a non-compulsory scheme, the scheme has the right to apply late joiner penalties, i.e. premium loadings, where the member cannot demonstrate adequate cover on medical aid since April 2001. Other factors to consider when allowing staff to choose from more than one medical aid: Higher administration IRO payroll wrt ensuring that exact payments to all relevant medical schemes are made. Reconciliations for more than one medical scheme per month. When annual reviews are done, more productive time used for staff to attend various medical aid sessions to determine which medical aid they will make use of. When one...

FACTORS TO CONSIDER WHEN CHOOSING A MEDICAL SCHEME

  Herewith the factors I consider when assisting my clients both corporate and individual to select a medical scheme: Ensure the financial stability of the scheme: Regulation 29 of the Medical Schemes Act prescribes that the minimum accumulated funds of medical schemes should be at least 25% of gross contributions. Is it a well established scheme – with much consolidation in the market it is preferable to look mostly at established brands with a sound track record Service Levels – Service is key and it is important to look at service in terms of how claims are paid as well as the communication in place to allow members to keep on track of claims processing.  A superior call centres as well as dedicated client liaison officers who are able to meet with clients and resolve member problems on site are essential. What claims get paid from what benefits – members need to understand where money is drawn from, for example: does the scheme pay for certain out of hospital benefits from an out of hospital expense day to day benefit or savings The administrator of the medical scheme as well as the fees paid iro the administration. The organization responsible for Managed Care? How do they manage access to hospitals – do they make it difficult for staff to access hospital care? Age profile : The higher the average age and pensioner to active member ratio, the higher the financial risks Have schemes increased contributions in line with the industry? Size of medical scheme: In this industry size does matter! The law of large numbers basically relies on the...