Medical Aid schemes: How to avoid shortfalls

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By Donald Tafadzwa Chidoori

Everyone who has ever joined a Medical Aid Scheme (MAS) does so to cover a rainy day. Actually the reason why people have health insurance in the first place is to protect their wallets. With how expensive health care currently is in Zimbabwe, one can only be happy to have an insurance umbrella for chronic illness, pregnancy, elderly parents, children or just themselves that covers everything. However, assuring that patients with health insurance are not burdened with excessive out-of-pocket costs (shortfalls) is a key challenge not only in Zimbabwe but the world over.

However, unlike in other countries, too much meddling in the health ecosystem, an impasse between health funders and service providers over tariffs, among other contested matters has led to the problem of shortfalls in Zimbabwe.

Shortfalls are the difference between the tariff stipulated by the Association of Health Funders of Zimbabwe (AHFoZ) for certain procedures and the actual costs for the procedures. For example for a General Practitioner (GP) visit the AHFoZ tariff is $25, while the actual cost for most GPs is US$50. So the shortfall $25 (AHFoZ Tariff $25 – Actual Cost $50 = $25) will be funded by the patient.

Because of these shortfalls many people have been left with huge bills after being hospitalized and have either been forced to fork out money from their pockets to cover for the shortfall or are left riddled in debt.

Being hit with an unexpected shortfall can be extremely unwelcome, but there are ways to prevent the situation.

So how can one safeguard their finances, avoid being left with huge bills or rather avoid shortfalls altogether?

Do your Homework and Get Quotations

The first way to prevent a shortfall is to know the amount your MAS will cover and the costs your specialist will charge for performing a procedure. So always ask your MAS how much they will pay for a procedure and compare it with the charges your specialist is charging this will give you an opportunity to negotiate the tariff with your specialist or look for an alternative specialist who offers the same quality services but who is within your price range.

Health services in other countries especially South Africa and India are cheaper and it’s a good thing that most MAS have full cover for foreign treatment so getting a quotation will help you know your options and you can save a lot from out of pocket expenses you experience during hospitalization.

Government Hospitals and council clinics also offer more affordable services and reduce the burden of shortfalls. However, services at some of these institutions are deplorable leading many people to opt for private health care. If you intend to be treated privately, check that you’re fully aware of the fees and how much of your treatment will be covered by your medical aid scheme. Include fees for extra things like bedding, medication, specialists and assistants’ charges that can quickly bump up the costs.

Get GapCover

A number of insurance companies are now offering an Insurance product known as GapCover, which covers the difference should the specialist charge you more than the AHFoZ stipulated tariffs.  GapCover will cover up to 400% the difference in cost, depending on the insurance provider. The cost of gap cover in Zimbabwe ranges from between $2 – $20 per month for an individual or family and is relatively cheaper than the charges in South Africa which range between R95 and R100 per month for family or an individual.

With the ongoing increases in premiums for medical aid schemes especially for individuals, GapCover is a constructive add-on to your medical aid to shield you from the surplus hospital or medical expenses.

GapCover can also make your health cover more affordable. With GapCover you can take the cheaper option from a Medical Aid Scheme and top it up with a GapCover. This has the potential to eliminate out of pocket expenses while you are hospitalised.

BEWARE – GapCover only pays for shortfalls on all procedures authorized and paid for by the member’s medical aid society. Gap Cover does not cover for costs of specialist consultations and procedures that are not covered by your medical aid scheme. 

Arranging Gap Cover insurance can go a long way towards minimising out-of-pocket expenses or avoiding them altogether, so it is important take out additional coverage to be sure that any shortfalls will be covered.

Hospital Cash Plans

Health cash plans are supposed to shield people from incurring unmanageable debt from medical expenses. Most medical aid schemes have limits. And when you reach these limits you are forced to pay for medical expenses on your own. This usually happens when your medical aid cover runs out and you are supposed to stay in hospital for a few more days.

These hospital stays can be extremely expensive and it is not something that you can afford to pay out of your own pocket, this is where the hospital cash plan really helps you out because it pays out a fixed dollar amount for each day you spent in hospital. This money can help you with your medication, and exclusions that are not covered by your medical scheme. Hospital Cash Plans are especially important when covering shortfalls on prescription drugs or when buying some over the counter drugs that are not covered by your MAS.

CAUTION – The hospital cash plan is not an alternative or replacement for medical aid. Hospital cash plans alone cannot offer you enough to make use of private hospitals but can work if you are on a medical scheme and want to make additional provision for co­payments or unknown costs not covered by the medical scheme option.

A hospital cash plan is simply a form of personal insurance that reimburses you for the loss of income due to hospitalization.

Unlike GapCover, Hospital cash plans can be taken by those people who cannot afford a medical scheme and intend to use private or state facilities when hospitalized. Hospital Cash Plans are significantly cheaper than medical schemes and can cost from just a $1. This policy is then used to cover incidental costs related to the hospital stay.

Exemption from Pay as You Earn (PAYE) deductions 

The majority of workers in Zimbabwe who have Pay As You Earn (PAYE) deductions are not aware that they can be exempted from PAYE deductions until they clear medical services shortfalls.  So if you pay shortfalls to your specialists, you can recover half the money you spend through exemption from PAYE deductions, of cause only after showing proof of payment.

This means that nothing will be deducted from your wages until the money owed to you as an employee is cleared. While this might not cover the full shortfall it will definitely reduce the burden of out of pocket payments and a big relief to employees who have been paying huge sums of money in shortfalls.

Under Zimbabwean law if as an employee, you pay for medical expenses or buy drugs or invalid appliances such as artificial limbs, wheelchair or glasses that are not covered by your medical aid scheme; you are allowed to claim 50 percent of that cost. As such the employer should not deduct PAYE from you until 50 percent of your medical costs are refunded. So go and ask for that exemption from your employee it will save you from paying lots of money in unexpected medical costs.

Health fund agreements

Some health funds in Zimbabwe have agreements in place with service providers, that is; hospitals, clinics, doctors or pharmacies so that patients won’t experience shortfalls, or will only have to pay minimal out-of-pocket expenses. It is important to check if your health fund does this. You can call your Health Fund to see which service providers have an agreement with your health fund. Some health funds also have agreements in place with specialists, optical and dental providers, as well as laboratories. If you choose to use a hospital that doesn’t have an agreement with your health fund, it is at your own peril as out-of-pocket costs will be inevitable.

The long standing impasse on medical services tariffs between AHFoZ and the Zimbabwe Medical Association (ZiMA), has been costly to the patient in Zimbabwe, and is the major cause of shortfalls in the country. However, some health funders have agreements in place with certain doctors, involved in your treatment, these agreements can cover some or all your hospital costs and some even settle claims based on ZiMA tariffs and by the Provider’s Association tariffs e.g. the Gynae’s Association, Anesthetist’s Association. So always check with your health fund to see which doctors they have an agreement with before undergoing specialist treatment or surgeries at hospitals. However, if you select to be treated by a specialist who doesn’t have an arrangement with your health fund, be ready to pay the shortfalls. 

Knowing service providers, doctors or hospitals in your health funders’ provider network can go a long way towards minimizing or avoiding your out-of-pocket expenses.

In House Treatment

Most big and or even small Medical Aid Funders in Zimbabwe have their own facilities and some of these facilities offer charges that are within the AHFoZ tariffs. So if you want to avoid shortfalls you should ask your MAS if they have their own facilities and where they are located. Many MAS in Zimbabwe also have their own, clinics, laboratories, hospitals and even train their own specialists’ doctors. So you can save money by being treated at a facility owned by your MAS and by having specialists’ procedures by Doctors at these facilities. While being operated on or treated by your own doctor who understands your medical history might be a welcome idea, his services might become expensive especially if his charges are above the AHFoZ tariff rates. So always check if your in-house facility has specialists that offer the same quality services as your doctor before getting yourself in debt.

So get treated at your in-house facility and use in-house doctors to give you a chance to significantly reduce the costs of your medical treatment and or even avoid shortfalls altogether.

Live healthy

This last insertion might come as a surprise to many, but yes leaving healthy pays. Being healthy can be cost effective. Because, eating healthy and consistent physical activity reduces the risk of chronic health conditions and diseases, including certain cancers, heart disease, stroke, diabetes and high blood pressure. In the long run these medical conditions can become costly, so by living healthy you can prevent them with the high probability of saving money through unbudgeted costs at the pharmacy, doctor visits, and even hospital stays each year.

According to Diabetes.org average annual medical expenses for a person with diabetes is $7,900. According to the Ministry of Health in Zimbabwe the cost of a chemotherapy session is between US$100 and US$1 000 per cycle, depending on the stage which the cancer has reached, while Radiotherapy costs between US$3 000 and US$4 000 for an entire course; so a healthy diet, living healthy, avoiding smoking and drinking and consistent physical exercises can help reduce your risk of cancer and other chronic diseases and help you avoid the hardships and exorbitant costs linked  with a cancer diagnosis, such as chemotherapy, regular hospital visits, surgery, prescription drugs and palliative care.

A healthy food regime can protect you against severe health conditions like heart disease, diabetes, high blood pressure, over and above seasonal illnesses like flu. This leads to the reduction to the expense of a doctor office visit and medication.

Medical aid premiums usually rise due to an increased claims ratio, so by staying healthy you will minimize the claims ratio, pulling down the overall cost of health care, leading to lower subscription rates and this increases the affordability of health insurance products.


ABOUT OUT-OF-POCKET COSTS

These are expenses for medical care that aren’t reimbursed or covered by your health insurance. Out-of-pocket costs include deductibles, coinsurance, and co-payments for covered services plus all costs for services that aren’t covered.

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