Medical Aid for Families: What You Actually Need (and What’s Costing You Money)

Madge Booth (00:22.405)

Okay, welcome to the moments podcast for working moms building careers, raising families and trying to make the best decisions with the time and money they actually have. So you know the feeling when you just want to cry or run away when you’re trying to find the best medical aid for your family. Because number one, you don’t understand half of what you’re actually reading. Number two,

Liz Coetzee Coetzee (00:46.702)

Number one, you don’t understand half of what you’re actually reading. Number two, the whole process is filling you with fear and dread. And number three, if you make the wrong choice, it could mean you’re not covered for the worst and you’re putting your family in financial danger.

Madge Booth (00:51.591)

The whole process is filling you with fear and dread. And number three, if you make the wrong choice, it could mean you’re not covered for the worst and you’re putting your family in financial danger. Medical aid is one of those things we all pay for, but very few of us actually feel confident about it.

Liz Coetzee Coetzee (01:07.66)

Medical aid is one of those things we all pay for, but very few of us actually feel confident about it. You could be spending thousands on your medical aid every month, and there’s a very real chance that right now you’re either overpaying and undercutters.

Madge Booth (01:14.141)

You could be spending thousands on your medical aid every month and there’s a very real chance that right now you’re either overpaying and undercover. And the scary part is that most people don’t realize it until it’s too late. Because the truth is medical aid isn’t just complicated. It’s often misunderstood, misguided and built on assumptions that don’t always serve

families. So today we’re talking about what you actually need and what you don’t, where families are wasting money and the decisions that matter more than you think. Because when it comes to your family’s health, guessing and not understanding the whole system is very expensive.

Liz Coetzee Coetzee (01:46.648)

So today we’re talking about what you actually need and what you don’t. Where families are wasting money and the decisions that matter more than you think. when it comes to your family’s health, guessing and not understanding the whole system is very expensive. I’m joined by Liz Gutzier who works closely with families navigating medical aid decisions every day and has a

Madge Booth (02:06.333)

I’m joined by Liz Coetzee who works closely with families navigating medical aid decisions every day and has a front row seat to the mistakes, the myths and what actually works. Welcome, Liz.

Liz Coetzee Coetzee (02:23.55)

Hello.

Madge Booth (02:27.165)

So Liz, you’ve been on many sides of the system. You were a nurse, so you’ve got the medical background. You’ve worked with different brokers. And in your own practice, you help moms make the best decision for their families. In your experience, are most families over-insured, under-insured, or just badly advised?

Liz Coetzee Coetzee (02:53.318)

I think I would always put it down to bad advice because a medical aid specialist is somebody who will first ask you for your needs and what is important to you and they build a product around that. So a good health advisor, if they take everything into cognizance and they should be giving you the correct

option to go on and maybe a gap backup and yeah and then cost of course. Cost sometimes if you can’t afford it well they’re going to maybe have to give you less but then you need to know what to look out for but it all comes down to a good advisor asking for all your needs taking them into consideration and giving you options to choose from.

Madge Booth (03:35.817)

Okay, that’s very interesting. So what are the non-negotiables like the basic cover every family should have?

Liz Coetzee Coetzee (03:47.243)

Okay, so starting with that needs analysis obviously to know what it is that they need. So it’s very difficult because you get young, you get old, you get people with diseases, you have children with autism. So the information that the client gives first is most important. Then of course, when we look at a medical aid, we must also decide

which hospitals are important to us. Because you get plans who give specific hospitals and if it’s not one that’s near to you or that you don’t want to use, then you’re having big penalties. So that’s a very big consideration is which hospitals can you use and are you comfortable with that? And then from then on it’s to look at the expensive benefits that you might need. So I often look at MRI CT scans.

I look at prosthesis, I look at cancer, very important. And then we look at copayments because a lot of the plans are much cheaper, but they have a lot of copayments, money you have to put down before a procedure. And then together with that comes the exclusions. You often see on a brochure that something is covered unlimited at PMB and everybody gets excited. But that PMB actually means that benefit is excluded unless you qualify.

So clients need to understand those are your four basic biggies with inner medical aid. And then of course, the moms will be saying, yeah, and what about GPs, dentists, medication? So in my opinion, the most important is the hospital cover and the cancer cover and the press. That’s your risk benefits, the very expensive ones. So we would look at you as a client and we have to decide, okay, you don’t have back hip or knee, you are 20 years old and you sit at a desk job.

So we don’t mind looking at benefits that might exclude back neck, and knee. But if you’re a farmer or if you’re doing any physical work, then we have to look at a product that surrounds that. So the important thing is, is the benefit going to cover your needs? Is the hospital that you want to use the appropriate hospitals? MRI CT scans, for some it’s not so important as others, but nowadays you battle to get an appointment for an MRI CT scan because they are being used quite a lot.

Liz Coetzee Coetzee (06:02.54)

So it is a benefit that can suddenly arise. It’s a risk benefits are unexpected things that cost a lot of money. So those are the things we are looking at. And then the clients will have to decide what is more important hospital day to day. So you can go on plans that give you better day to day, GPs when you talk about day to day, the savings component, those that get money upfront in a year and you have to spend it, manage it well over 12 months.

because it usually doesn’t last that long, but that’s also because we don’t manage the savings properly. And then preventative care. Preventative care is a very important thing, and a lot of people don’t even know they have those benefits. So those benefits would be like a mammogram once every two years, or for older people, bone density scans, men’s prostate tests, and then children immunization. Mommies that are having babies,

must look at plants that are specifically designed around maternity. So they will give you gynecological visits. Some give eight, some give six, some give 10, some give 12. You don’t pay out of pocket, they pay for it. So that’s a nice to have benefit, but it could be quite a lot of money. And things like immunization, a lot of medical aids do pay for immunization, and that’s also very expensive.

So that’s also something to look at if you’re pregnant. So you see, depends who you are and where you are. Once again, it comes down to your needs, that you need. So whatever it is you need has to be addressed. And the rest of the product, are you OK with the co-payments? Do you understand what is not covered unless life threatening? That’s those P &B benefits. Do you understand which doctors you have to use because medical aides have networks or they call it DSP?

a designated service provider. And if we don’t stick to the medical aids list of doctors, hospitals, medication, we have huge short and co-payments. And those who don’t have the gap cover are going to be paying a lot out of pocket. I hope that answers your question.

Madge Booth (08:05.095)

Yes, yes it does. It’s very comprehensive. So it’s very important that we review our plans as our situations and our families grow and in the different stages of our lives. So how often should a family review their plan?

Liz Coetzee Coetzee (08:09.166)

very comprehensive. So it’s very important that we review our plans as our situation and our families grow and in the different stages of our lives. Absolutely. So a lot of them should family review their plans. Every year. Every year. The first thing you do is you, I always suggest is you take your claims history transaction. You go look at where

from January to what we start usually reviewing by September. Where did all your claims go? What were they for? Did you come out with it or didn’t you come out with it? Because when I look at a client, that’s what I will do. Because some people will say, no, they want to go on a more expensive plan because they want more day to day. But that’s usually a bad decision because you’ll usually pay much more, but you won’t get round for round benefits back in your day to day. So sometimes we go down to a cheaper plan.

And we build up our own day-to-day on the sideline. And we get far more savings or day-to-day benefits that we would have had on more expensive plan. So it is important to review. If you are happy, you came up with your benefits, there’s no new conditions, you’re not pregnant. People with cancer, very important, must review as well, because the benefits work differently and there are limits that get exceeded and stuff like that. So it’s very important for you first to review.

Were you happy that everything worked? If something’s broken, we don’t want to fix it. But any new events, any new stages, kids going to university, there are student plans. So you don’t have to pay more expensive for them. But the student plans also have exclusions. So you must make sure you get a gap cover for that. I don’t want to, sorry, I do talk too much about it, but it’s not an easy answer. But yes, please, they must review and chronic.

chronic, I left that out earlier. Most people don’t use their chronic benefits correctly either. So that needs to be reviewed every year as well. Yes.

Madge Booth (10:11.377)

Okay, so that kind of leads into my next question, which is a very interesting part of the conversation I think many moms actually wonder about. And that’s how moms can use their medical aid more strategically instead of just reactively, instead of just claiming when something went wrong or someone’s sick, how can they sit at the beginning of the year and plan to use their medical aid to their own benefit?

Liz Coetzee Coetzee (10:14.19)

leads into my next question, which is a very interesting part of the conversation I think many moms actually wonder about. And that’s how moms can use their medical aid more strategically instead of just reactively, instead of just claiming when something went wrong or someone’s sick. How can they set at the beginning of the year and plan to use their medical aid to their own better health?

So that’s exactly why we would review. We’ll see what they’ve done and where they are going to for the next medical aid year. So the things that would be important to them would be if they had babies, the immunization and the costing of that. And then it would be things like the preventative care benefit. Well, that’s with immunization for sorry. And then the day-to-day needs, know, what really are because that’s what it would be when it comes to kids.

And then what they must be very careful for is if they choose to go to these, what we call them low income options, a lot of them don’t pay for tonsils, adenoids anymore. So you can have a gap cover for that, or you might then need to go to a different plan. Sometimes we split the membership and we have dad who’s maybe more ill on a better plan to cover his back, knees, and mom is earning an average salary.

a half day job with the kids and we put her on a plan that gives more day to day benefits. So in understanding what you need, once again, you must speak to a specialist. You have to look at your claims for the previous year, where it went and was it once or is it something that’s gonna happen often? Unfortunately, there are things that the medical aid won’t pay for. And it’s usually when people have a lot of…

occupational therapy or speech therapy or stuff like that. Usually the more expensive plans pay for that. But once again, we do the sums. What does that expensive plan cost compared to a basic plan? The difference in premium with times about 12, you see how much more that plan is going to cost you over a year compared to what you pay for occupational care or speech therapy. And then of course, we’ve got the tax benefit. So we’ve got the credits currently, they have increased them a bit.

Liz Coetzee Coetzee (12:27.596)

So how can you use the tax credit to also help you to get money back when you pay stuff out of pocket? And usually the best advice is the person who earns the least is the one who should be the main member, but you must be a taxpayer because they take a percentage of your personal income to decide how much you spend before they are going to give you money back in tax benefits. So one has to look at all those things. So from the mom’s perspective, if it’s kiddies,

and they’ve got flus and cold and all that sort of stuff, how can you manage it? You must look at the type of plan that suits that narrative that you need. So it’s a very broad question. Sorry, so if I’m not answering it properly, do let me know if you were thinking of something else specific.

Madge Booth (13:15.817)

No, no, this is very, very interesting. I was also wondering, so let’s say you’ve got your savings and you didn’t really use it. And then for what can you use it when you see, the year is almost done and I still got quite a bit in my savings account. What can moms do to benefit them and their families with what’s left in their savings account?

Liz Coetzee Coetzee (13:43.517)

Okay, so I mentioned earlier these different types of day-to-day benefits. So savings is one of them.

And then there are benefits where they give you optometrist benefit. They give you a dental benefit for a random value, but it’s not savings. So the benefits that are not part of savings, those are your use it or lose it benefits. So those are the benefits. If you know you haven’t done glasses in two years, then you use it for this year. Another thing that people often do is hearing aids. You get an amount for a year. So they usually do in December the one year in December.

and the other year in January. And it’s the with anything that’s very expensive with regards to if you have the benefit with a limit that you split it between December and January. So that takes a bit of planning. Day-to-day benefits are what we call your traditional options. So most options have a bit of savings, but there are plans that have just day-to-day. ProfMed is an example. ProfMed is obviously for professionals, but it does have a random amount that it gives for

GPs or dentists or whatever, and what you don’t use, you lose. So those are the benefits you will look to. You’ll see what you have per year, what have I not done yet. Savings is actually your money. It just sits within the scheme. You must manage it. I get very cross when a doctor or dentist or a physio or whoever, I’m not blaming anyone specific, says, your medical aid will pay for it. It’s coming out of your money. That’s saving for just as well be in the bank. A savings accounts like a lay-by.

They give you a lump sum in January, and you’re actually paying it off over 12 months interest free. When you get to the end of the year, it carries over. So you don’t have to, please don’t use it. Please leave it there. Then I’ve had clients who’ve built up their savings to large amounts. So what we do at a certain stage in the year, if your medical aid allows it, we downgrade to a plan with no savings. And we get the savings paid out to the client.

Liz Coetzee Coetzee (15:45.036)

and then in January we go back again. So that’s something one can do. But savings, please guys, it’s your money. Don’t use it for over the counter medicine. If you really end up the month salty, correct? Sorry.

Liz Coetzee Coetzee (16:02.402)

So yeah.

Liz Coetzee Coetzee (16:08.874)

I’m so sorry. If you get to end of the month, so it get a pause.

Madge Booth (16:11.097)

Yeah, it’s fine. It’s 100%.

Madge Booth (16:17.513)

I’m Hannah from Edde.

Liz Coetzee Coetzee (16:20.142)

Thank you,

Madge Booth (16:23.911)

Your near fat is dead.

Madge Booth (16:29.447)

Well, okay.

Liz Coetzee Coetzee (16:31.342)

Okay.

Madge Booth (16:33.437)

That’s fine, that’s fine, right?

Liz Coetzee Coetzee (16:39.621)

Come and chat.

So if we get to the end of the month salty cracks where the budget’s really tight, of course you’re going to use it. But don’t use it for silly things, things that you can pay for yourself. Also just remember, over-the-counter medicine, or we call it schedule 0-2 medication, cannot be claimed back from tax. So for people who are keeping slips, don’t do that to yourself. It’s unnecessary work. Unless you schedule three and above, will they consider in paying you back?

Madge Booth (17:13.301)

my word, that’s so interesting. Thanks for sharing all these interesting facts with us. So is it smarter to pay some things in cash instead of claiming? Am I understanding that part right?

Liz Coetzee Coetzee (17:14.254)

Oh my word, that’s so interesting. Thanks for sharing all these interesting facts with us. So, is it smarter to pay some things in cash instead of claiming? I understanding that right? Yes, you are. It is smarter sometimes. What you must remember is that some companies are contracted to medical aid for a lower rate and other companies are not contracted or they’ll be

not contracted so they’ll charge more. So you have to ask the service provider. One thing about being a medical aid client, Consumer Protection Act is there for you. So you must ask every doctor, every dentist, any fisher, anybody who treats you, especially teeth. Teeth dental is a major issue nowadays and so expensive. What do they charge? The rates that they charge?

What is the cost for something that they want to do? is that what they’re going to do? Something that you can afford to pay out of pocket, obviously, and is it really necessary? But they have to tell you before the time that it costs so much or you’re to have a co-payment. A lot of the doctors do have letters, especially gynaecologists, because they are the most expensive doctors currently, have a letter warning you about stuff. But when it comes to things like medication,

Sometimes it is cheaper to pay cash. It depends on the rates that the chemist will charge or not charge. I have a physiotherapist, my personal physiotherapist, her medical aid rates are cheaper than her private rates. So it’s just something you always have to ask before the time. That’s the main thing with medical aids, ask and they have to answer you.

Madge Booth (19:05.033)

Okay, that’s very, very good to know. So if a family is on a tight budget, you mentioned the salty cracks just now, we all know, we all have those months or weeks in a month. When does it make sense to downgrade and when is that a dangerous move?

Liz Coetzee Coetzee (19:05.132)

Okay, that’s very, very good to know. So, if a family is on a tight budget, you mentioned the salty cracks just now. We all know, we all have those months or weeks in a month.

When does it make sense to downgrade and when is that a dangerous rule? Well, I have a whole lot of those. We have been so busy this year with people who just can’t afford medical aid. So it’s a difficult decision and it’s the client’s decision. What we will just do is we will first of all look at exactly what you say, what health issues are there. Will it be covered as what we call PMB? So PMB is a prescribed minimum benefit.

The Medical Schemes Act of 1998 tells you that there’s 271 conditions that medical aides have to pay. But you have to qualify and you must use their doctors or their medicine lists or whatever. So we must first of all look at that. Is the illness that you have, PNB, are we okay to downgrade because you’ll be fully covered? Sometimes some medication is not going to be covered. Then we look at costing.

What we do is, which I mentioned earlier, is we can split the medical aid. So if mommy’s earning far less than daddy or daddy is earning far less than mommy, and he’s healthy, and he just wants hospital care, and he doesn’t need anything else, then we can downgrade him to something like that. The difficult thing about moving medical aids is that you always potentially have a waiting period. There’s one medical aid who currently do not give waiting periods. I’m not going to mention that.

But then you have to be on a medical aid and then you go over to a new medical aid for that specific company. But other medical aids have to measure the risk. If you’re very ill and you’re to join them, you’re going to cost them a lot of money. So if they feel that that’s the case, then they’re going to give you that waiting period.

Liz Coetzee Coetzee (21:16.216)

So that’s also something, can you afford the waiting period? Do you mind the waiting period? Are you an anxious person? It’s not gonna work for you. But downgrading is not a bad thing. As long as you look at your highest risk benefits that are important to you. Family history is also very important, once again. So no, not lot of people. And that’s what CapCover does. CapCover is actually not good for medical aids because on a medical aid, you should be on the plan that suits your needs. That’s why you pay that price.

So we are putting a lot of older people on lower plans that they shouldn’t be on because they can’t afford anything else, you see. So then we get the gap cover and the gap cover helps us to top up where the short payments are, co-payments are, doctors’ rates are too high compared to what the medical aid is prepared to pay. So it is a good idea as long as the sums work and we look at your needs.

Madge Booth (22:17.691)

Okay, thank goodness for gap cover in that case.

Liz Coetzee Coetzee (22:20.59)

Yeah.

Madge Booth (22:25.255)

So if you had to choose one plan type

Sorry, I can’t do it again.

Liz Coetzee Coetzee (22:34.31)

Sorry.

Madge Booth (22:36.263)

Yeah, it’s fine.

Liz Coetzee Coetzee (22:38.698)

I’m sorry.

Madge Booth (22:42.288)

again.

Madge Booth (22:46.001)

Yes, fine. So if you had to choose one plant type for a middle class family with two kids, what direction would you lean and why?

Liz Coetzee Coetzee (22:49.55)

So if you had to choose one plant type for a middle class family with two kids, what direction would you lean and why? Okay. So once again, it depends on the dynamics and the needs and stuff. So people who don’t worry about hip replacements, knee replacements and that sort of thing, must name the companies.

Madge Booth (23:15.346)

Yeah, I reckon.

Liz Coetzee Coetzee (23:18.263)

Okay, so the plan that I look at, I work with eight different medical aids, but I don’t necessarily put people on some of the medical aids. I receive clients who are on those medical aids and you don’t always have to move them away. So when you work with a health advisor, it’s important to ask,

how many medical aids they’re working on. If they’re only working for one company, then only momentum, only discovery, then you’re not getting proper advice because they’re only going to sell you what they can. So you need somebody who works with more, at least, I would say at least three or four, the top four. So best made, B2 network is an awesome plan with regards to costs.

And it gives enough of everything. They’ve taken away co-payments this year. So that gets taken away for money out of pocket. And they’re a friendly medical aid, very consumer friendly, nice medical aid to be on. But they just have the exclusions on prosthesis. So that’s the prosthesis. Prosthesis, guys, is anything you put in your body that’s not your own body’s material. So anything that is a device, a wire, cement.

that is a prosthesis. So it’s anything from a pacemaker, a stents, a mesh in your stomach, they also put stents in your bladder, all those things are prosthesis, together with hip replacements, knee replacements, back fusion operations and those sort of things. So if you don’t mind those being excluded, then we put them on there because they’re a young family and that’s what they need.

If there are issues, then we look at Momentum’s customer-associated state option. So that’s a hospital plan. But they allow you to create your own savings within that benefit. So where, for example, if you go to Discovery Medical Aid, your savings is fixed. It’s there. That’s the amount you get. It’s part of your premium. If you go to the customer-associated state option, it’s the cheapest hospital plan, and it’s the best hospital plan.

Liz Coetzee Coetzee (25:26.092)

in the market because of the benefits it offers. Discovery will be just there after. So you put a company on the customer-associated. Why? Because associated means you have to use a list of hospitals. And all these plans that use a list of hospitals, some of them are very limited hospitals on offer, where momentum has many hospitals for you to choose from. So first of all, you’ve got safety in that with regards to not using the wrong hospital and getting a massive penalty.

Then it covers MRI and CT scans in and out of hospital. But on the custom option, you’re going to get copayments with every hospital admission, and they have copayments on top of that for things like scopes, atroscopy, laparoscopy, endoscopy, those sort of things. So gap cover is very, very important. And then also you can create your own savings. So you can pay less and create your own savings within momentum.

And it works like a normal savings account. So that’s very awesome. And then Momentum has great maternity benefits. So that would, for a young, average family who’s looking for immunization or stuff like that, that would be a good hospital plan. Because everybody always has hospital plan. So those would be the two that I would start off with. And then Discoveries got a plan called a classic Delta saver and a classic smart plan, in my opinion.

Discovery has the best cancer benefits and the best prosthesis benefits and they are very innovative with technology. So when I sit with people who have conditions that fall to that, then I would rather look that way or once again, I’ll split the membership. I’ll put the adult that needs the more technically advanced benefits and I’ll take mom and kids and put them on something else. What’s also very important for the average size family is that their kids go to varsity.

There’s a few medical aides that keep the rates that you pay at child rate till age 26. So those, I get a lot of those people because the student benefits are nice for GP, dentist and sort of stuff like that, but they don’t give good quality hospital care. So sometimes if they can stay on with the parents, the parents keep that tax credit as well and they stay children rates until age 26.

Liz Coetzee Coetzee (27:50.787)

That’s far more affordable than being on a medical aid where as soon as you turn 21, you’re pay adult rates. So that’s also something I would look to is how old are the kids and can they move to student plan? Would it be okay? Or is it better to keep them on with regards to cost? the network B2 of best met is one of those options that keep kids at kids rates until 26. And if you’re a professional person,

you’re a physio, you’re a dentist, you’re a lecturer, those people have also a very good hospital plan, and they can also create their own savings through the wallet. So it works the same way as Momentum does, the customer-associated state, and they don’t have the co-payments that Momentum have, but they don’t have good MRI CT scans. You see, so you play those things against each other. But those plans, I’ve just quoted a mommy who’s suffering financially, so she just wants her kids covered.

So some medical aids allow you to just put children on the medical aid. And to put the two kids on the medical aid, the benefit works out to around about 2,700 grand. But because she’s a physiotherapist on ProfMed, that can all be covered with a very good hospital plan for 2,700 grand. So the mom must now make the choice. Does she want her kids to have the GP dentist benefit or will she manage that?

or does she want them to have good hospital care and then she is covered? My advice would of course be the hospital cover because what happens if mommy falls ill? You don’t want to send it to a state hospital.

Madge Booth (29:29.469)

Yes. my word, Liz, your advice is so helpful and it’s so practical. I am so glad we had the opportunity to chat and that you shared your knowledge with all of our listeners. I just realized again that medical aid isn’t something you just sit and forget. It’s something that needs to evolve with your family, your budget and your reality.

Liz Coetzee Coetzee (29:48.076)

I just realised again that medical aid isn’t something you just sit and forget. It’s something that needs to evolve with your family, your budget and your reality. And if this episode made you pause even just slightly, it’s probably worth taking a proper look at your current cover and speak to Liz or another professional who can chat you through every process.

Madge Booth (30:00.113)

And if this episode made you pause even just slightly, it’s probably worth taking a proper look at your current cover and speak to Liz or another professional who can chat you through every process.

Liz Coetzee Coetzee (30:18.743)

Very important to choose. Okay, thanks.

Madge Booth (30:18.845)

Thank you, Liz.

Madge Booth (30:24.617)

Yeah, you can say, very important.

Liz Coetzee Coetzee (30:25.09)

Thank you. It’s just very important to please make sure it’s a health specialist because there are advisors that do life and invest and they do medical aid as a hobby. Please don’t use them for medical aid and they often tell you to keep all your policies in one place. Why? It’s not really inconvenient for you. The most important thing is that somebody gives you the correct advice. Otherwise, you’re going to have financial issues or medical issues. So please do make

sure you use a health care specialist. Thank you.

Madge Booth (31:00.209)

Amazing. Thank you, Liz. And thank you for your time.

Madge Booth (31:08.081)

Okay, you record in stop?

Liz Coetzee Coetzee (31:09.807)

And the recording is finished.