Healthcare consumers always face the hassle of choosing an appropriate medical aid plan for themselves, considering the vast number of options on the market. For the past 2 months, our team has been conducting research on the medical scheme market and reviewing some of the available medical schemes, such as the one under review in this article.
In this article, we look at the plans offered by the CompCare Wellness Medical Scheme, which happens to be one of the longest-serving schemes in South Africa. As you read on, you will get an insight into the structure of the medical aid plans and how CompCare operates in .general.
The following is the list of options offered by CompCare. The parameters of each option are discussed thereafter:
SELFNET; MEDX ED;
This is the entry-level option, most suitable for young individuals or families who want basic hospital cover coupled with minimum chronic benefits. Selfnet allows you to manage your day-to-day medical spending by means of a medical savings account.
Major medical expenses or hospital benefits are paid at 100% of the scheme rate unless specified otherwise. Benefits have an unlimited Overall Annual Limit. CompCare members are supposed to use Netcare facilities for their hospital procedures to avoid co-payments. However, should you use another health care facility other than Netcare, you will be liable for a 30% co-payment toward the bill.
CompCare’s minimum co-payment is R10 000, meaning that even if the 30% of your bill is less than R7 000, the scheme will expect to receive R10 000 as co-payment from you. Members are responsible for getting authorisation for non emergency hospital events and also should try to use Netcare facilities to avoid co-payments.
Selfnet subscribers’ hospital benefits paid from the scheme risk include GP visits, radiology, specialists, surgical procedures, and blood transfusions. All these specialists are paid at a 100% CompCare scheme rate.
While admitted to the hospital, patients’ medications are covered by the scheme. Upon being discharged, CompCare will cover a 7-day supply of out-of-hospital medication at a 100% scheme rate.
The SelfNet day-to-day benefits are subject to your medical savings account balance, yet paid at 100% of the scheme rate. So for 2021, an adult’s annual savings allocation is R3 648, while a child’s dependent allocation is R1 284.
The day-to-day benefits include prescribed and over-the-counter medication, consultations, basic dentistry and optometry, basic and specialised radiology, pathology, and GP specialists, among other benefits.
Benefits paid from scheme risk
Unless stated otherwise, CompCare Wellness pays the following benefits from the Scheme Risk:
Once you are registered, CompCare covers all the 27 chronic conditions without any benefit limits or co-payments, provided the medication is on the scheme’s formulary and matches the reference price of the product.
Prescribed Minimum Benefits
All PMBs are covered as described in the Medical Schemes Act. These include organ transplants, renal dialysis, and plasmapheresis.
In the event of an emergency, members can contact their medical emergency services provider, Netcare emergency, on 082 911. Clients will be required to pay a 25% copayment if authorization is not obtained. To get authorisation, members are expected to call during the time of emergency or at least within 24 hours after the emergency.
Members who test positive for the coronavirus have the benefits of;
COVID-19 related consultations (R400 PB)
PCR test: 3 per beneficiary over the age of 18 years.
One antibody test per beneficiary.
Principal member: R1 690
Adult dependant: R1 690
Child dependant: R597
MEDX ED Option
This is an ideal option for young professionals who are more concerned about getting comprehensive hospital coverage in a private hospital. Subscribers of CompCare’s MEDX ED option are mostly young and healthy people who can take care of their daily medical needs.
The MEDX ED option gives you unlimited comprehensive hospital cover in a private hospital. It’s even easier for members living near a Netcare hospital and willing to use DisChem pharmacy for their chronic conditions.
Just like the SELFNET option, major medical expenses or hospital benefits are paid at 100% of the scheme rate unless specified otherwise. The Unlimited Overall Annual Limit goes without question for the MEDX ED option, as it offers comprehensive hospital cover.
Part of the hospital’s benefits are listed below:
Pathology (limited to R26 800 PMF)
Auxiliary services: physiotherapy, biokinetics, dietitian… (limited to R3 000 PFM).
Surgical prosthesis (overall limit of R31 500 PFM, sub limits also apply)
Specialised radiology (limited to R24 000 PFM)
Day-to-day Medical Benefits
These are paid out from your own pocket. As mentioned earlier, MEDX ED best suits people who do not really need constant medical attention. However, subscribers may need comprehensive hospital cover to cover for rainy days when they need hospitalisation.
Benefits paid from scheme risk
All SELFNET benefits paid through scheme risk are also paid through the MEDX ED option. In both options, the CompCare scheme protocol applies.
Preventative care: that includes GP wellness consultations, health checks (blood tests), rapid HIV tests etc.
Emotional well-being: hospitalized psychiatric treatment, psychology (limited to R1 800 PMF), alcoholism, and so on.
Oncology and speciality care: unlimited oncology, including chemotherapy and radiotherapy.
Active lifestyle programmes: fitness assessment, nutritional assessment and healthy eating plan, cover for injuries.
Men’s health: prostate-specific antigen (PSA) blood test
Kid’s Wellness: Baby wellness visits, childhood immunizations, school readiness assessments, pre-school eye and hearing screenings, dental screenings, etc
Principal member: R1 741
Adult dependant: R1 741
Child dependant: R545
CompCare designed this product for people who are looking to get higher limits on their Personal Medical Savings accounts. The UNISAVE plan lets you control how much you spend on medical care on a daily basis, but it also gives you standard in-hospital coverage for when things don’t go so well for you.
Choosing this option will be ideal if you don’t really have any special chronic illnesses or diseases of concern and you are happy with the minimum benefits the scheme covers. As a result, your UNISAVE medical coverage is primarily for covering your day-to-day adventures, such as sporting activities and medical benefits.
Major medical expenses are paid at 100% of the scheme rates unless stated otherwise, depending on the service being received. Hospitalisation is unlimited and treatment can be obtained at any private hospital of your choice if all the authorisation procedures are followed.
Medicine in hospital and a 7-day supply after being discharged
Surgical Procedures out-of-hospital
Pathology is limited to R30 000 PMF for both in-hospital and out-of-hospital cases.
R2 500 PFM is the limit for physiotherapy, biokinetics, dietitians, and other auxiliary services.
Surgical prosthesis benefits are limited to R32 500 PMF.
The MRI, CT, high-resolution CT, and PET scans are limited to R26 500.
Day-to-Day Medical Benefits
The UNISAVE option has a lucrative savings account to cover daily medical expenses. CompCare sets aside up to R 811 for your Personal Medical Savings Account, which covers your daily medical expenses subject to the savings account balance.
The day-to-day benefits include the following:
Acute and over the counter medicine
Basic and specialised radiology
Pathology is also limited to R30 000 PFM.
Basic and specialised dentistry services.
Optometry is 100% of the SAOA rate.
Surgical appliances like wheelchairs and hearing aids
Benefits paid from the risk pool
The benefits paid from the CompCare risk pool are standard with almost all the options we have discussed above ( MEDX and SELFNET). Most medical schemes have standard benefits paid from the risk, like the 27 chronic conditions and all the prescribed minimum benefits.
Principal member: R2 709 annual savings is R8 112
Adult dependant: R2 310 annual savings is R6 924
Child dependant: R812 annual savings is R2 424
In this plan, CompCare offers a more comprehensive cover that surpasses the set standard that every medical scheme is supposed to offer. The MUMED option covers 37 chronic conditions, meaning there are 10 more chronic conditions included in the plan other than just the 27 prescribed by the law.
Mostly MUMED is an ideal plan for young families or individuals who are looking for a comprehensive cover that will not just cover the basics. In this option, you also get to benefit from innovative wellness programs like fitness assessments, exercise prescriptions, and healthy diet plans.
Major medical expenses have unlimited overall annual limits and are paid at 100% of the scheme rate unless stated otherwise. The hospital benefits include the following:
MRI, CT, high-resolution CT, and PET scans are limited to R27 000 PMF.
In hospital medicine and 7 days’ medicine supply after hospital discharge
Auxiliary services like physiotherapy, biokinetics, and dietitians have a collective limit of R3 100 PMF in and out of the hospital.
Surgical prostheses have an overall limit of R34 000 PFM.
Organ transplants and outpatient surgical procedures
For day-to-day medical expenses, CompCare has set aside the Annual Flex Benefit (AFB) to cover daily medical expenses. Even though the AFB is designed to cater for day-to-day medical expenses, it forms part of the scheme’s risk.
Here is a metaphor: CompCare sets aside an AFB of R6 410 for the principal member, and when the member incurs conditions that fall on the day-to-day benefits, the scheme pays the expenses from the AFB. If the AFB is depleted, the member will pay the balance of such expenses from their own pocket.
Even though the R6 410 (AFB) used for the day-to-day expenses forms part of the scheme risk (risk pool) benefit, it does not in any way affect your major medical benefits paid unlimitedly from the risk pool.
The day-to-day benefits covered include:
Acute and over-the-counter medicines
Basic and specialised radiology
Pathology, including the in-hospital benefits, is limited to R33 000 PMF.
Basic and specialised dentistry
Optometry includes eye tests, lenses, and contact lenses, as well as frames.
Surgical and medical devices
Principal member: R3 496 Annual Flexible Benefit (AFB) R6 410
Adult dependant: R2 725 Annual Flexible Benefit is R4 000
Child dependant: R983 Annual Flexible Benefit is R1 600
If what you are looking for is comprehensive hospital cover with a hospital of your choice coupled with complete day-to-day cover, then you have found yourself a medical plan.
SELFSURE offers more than the average cover. The plan covers up to 40 chronic conditions and also includes extreme adventure and professional sports cover in the plan. These are scarcely included in most medical schemes, and they are catchy benefits for someone who is active in life adventures. On top of these, the plan has added benefits for men, women, and kids.
Hospital benefits are unlimited and paid at 100% of the scheme rate unless stated otherwise on selected conditions. The hospital conditions covered are similar to those of the MUMED option. However, limits may vary with SELFSURE limits, which tend to be higher.
For instance, the SELFSURE in and out of hospital pathology limit is R33 000 PMF while their surgical prostheses are limited to R35 000.
Day-to-Day Medical Benefits
With the SELFSURE plan, day-to-day claims are paid from two benefit ponds. There is the Day-to-Day Extender Benefit, which covers radiology, pathology, basic dentistry, physiotherapy, and biokinetics for a set amount. Then the remaining out-of-hospital benefits are paid from the day-to-day benefit with a specified benefit limit applied.
Principal member: R3 645
Adult dependent: R3 645 per day, R4 080 per week
child dependant: R912
Annual Flexible Benefit is R2 040
If you are a growing family still interested in adventurous sporting activities and looking for a very comprehensive day-to-day medical cover, then SYMMETRY is your option. In this plan, CompCare brings you incredible Day-to-Day coverage that continues to cover some of your Day-to-Day benefits even when the PMSA and the AFB are depleted.
Among the 48 chronic conditions covered by CompCare, there is a popular trending disorder known as Attention-Deficit/Hyperactivity Disorder (most schemes do not include it). This is a common chronic condition affecting millions of children and may even continue into adulthood. Luckily, SYMMETRY plan holders are covered.
The SYMMETRY major medical benefits are also similar to the SELFSURE benefits. They all have no overall annual limit and are paid at 100% of the scheme rate. The difference is in the sub-limits on the benefits. For instance, auxiliary services are limited to R5 200 while in SELFSURE they are limited to R4 200.
The surgical prosthesis limit is R36 500.
MRI, CT, high-resolution CT, and PET scans are limited to R30 000 PMF and the first R1500 is payable from savings and AFB respectively.
Radial keratotomy and excimer laser services are limited to R5 000 per eye, including all hospital-related costs.
The daily medical expenses are paid first from your personal medical savings account and then from the annual Flex Benefit. Here’s the good thing about SYMMETRY: even after depleting the set day-to-day benefits, CompCare continues to cover some of your day-to-day medical events.
So, the R9 940 total day-to-day cover for the principal member is broken down as follows: R5 268 from the savings account, which is used first; then the R4 672 AFB limit is used last.
Then the adult dependent’s total day-to-day cover is R7 720, with an annual savings account of R4 104 and an AFB limit of R3 616.
The child dependant’s total day-to-day cover adds up to R2 770, which is the sum of the savings account of R1 488 and the AFB limit of R1 282.
The benefits paid by the scheme are similar to the SELFSURE benefits, with differences in the limits set on each benefit.
Contributions and Day-to-Day Benefits Principal member: R4 397 R9 940 Adult dependant: R3 429 R7 720 Child dependant: R1 241 R2 770
DYNAMIX ED Option
This is an ideal option for a mature family, maybe with grown kids in high school or varsity, looking for a comprehensive hospital cover with a great catch in the daily medical benefits.
The DYNAMIX ED option covers 65 chronic conditions and has comprehensive and unlimited hospital coverage in any private hospital. The plan gives you above-threshold benefits, meaning you and your family can be assured of cover even during a crazy year with extensive medical expenses.
Major hospital benefits are paid at 100% of the CompCare scheme rate and have an unlimited overall annual cover. Even though members can use any private hospital of their choice, there are 30% copayments at non-Netcare hospitals.
The hospital benefits in the DYNAMIX ED option are more similar to those of SYMMETRY, except that DYNAMIX is more comprehensive with 65 chronic conditions and higher limits and sub-limits on benefits covered.
Day-to-Day Medical Benefits
Day-to-day claims are initially paid from your savings account and then from your Annual Flexi Benefit (AFB) once the savings account is depleted. The set amount of savings that you can use for day-to-day claims per year is:
Principal member R7 680
Adult dependant R5 988
Child dependant R2 172
Then the annual flexi benefit per year is:
Principal member R2 580
Adult dependant R2 016
Child dependant R732
Making your total Day-to-Day benefits be:
Principal member R10 260
Adult dependant R8 004
Child dependant R2 904
In the event that you don’t use all your savings in a given year, CompCare carries the balance forward to the following year for your use.
Also, in another event where you use up your savings and AFB limits, CompCare provides you with an extended cover called the Above Threshold Benefit (ATB). To be eligible for the ATB, you will have to first pay some benefits from your pocket (self-payment gap). You can continue claiming even on the SPG stage.
The SPG paid before the threshold benefit is:
Principal member R6 660 Adult dependant R4 944 Child dependant R1 728
The threshold benefit is as follows:
Principal member R16 920 Adult dependant R12 948 Child dependant R4 632
Principal member: R4 579
Adult dependant: R3 572
Child dependant: R1 294
Pinnacle is the most comprehensive medical plan among the plans offered by CompCare. It has unlimited GP and dental visits and pays 200% cover for specialists in private hospitals.
Similar to the Dynamix option, PINNACLE also has a savings plan and an Above Threshold Benefit to cover unexpected medical bills that have exceeded the set limits. The option covers up to 74 chronic illnesses and allows you to be hospitalised in any Netcare hospital or ward with unlimited cover.
For chronic medicines, CompCare allows you to use any Dis-chem pharmacy and your medication will be covered at 200% of the scheme rate.
Major medical expenses are unlimited and paid at 100% of the scheme rate. Members of Pinnacle can visit any Netcare private hospital for any hospital-related accounts, such as GP visits and specialists. specialists visited are paid 200% of the scheme rate.
Apart from being comprehensive in the range of medical conditions covered, PINNACLE also has higher limits and sub-limits on benefit payouts. For instance, auxiliary services are limited to R5 200 in the Symmetry option while the limit is R10 500 in the Pinnacle option.
The Day-to-Day Benefits are subject to first the savings balance, then the AFB. When the AFB is finished, you pay from your own pocket (SPG), and lastly, the ATB.
The 2021 savings account is:
Principal member R14 796
Adult dependant R11 508
Child dependant R4 116
Then the annual flexi benefit per year is:
Principal member R3 480
Adult dependant R2 712
Child dependant R966
Making your total Day-to-Day benefits to be:
Principal member R18 276 Adult dependant R14 220 Child dependant R5 082
Once you have depleted your day-to-day benefits, that is your savings and the AFB, you will have to pay the day-to-day medical expenses from your own pocket (SPG) before the scheme threshold.
The self-payment gap for 2021 is:
Principal member R3 150 Adult dependant R2 180 Child dependant R650
During the period in which you pay your day-to-day medical expenses from your own pocket, CompCare still requires that you submit your claims. Once you have exceeded SPG limits, the scheme covers the following expenses using the Above Threshold Benefit:
ATB 2021 limit is as follows:
Principal member R21 426 Adult dependant R16 400 Child dependant R5 732
Principal member: R6 168 Adult dependant: R4 799 Child dependant: R1 718
Competitive advantages of the CompCare Wellness medical scheme
- The scheme has varying options that accommodate everyone, regardless of the income class, you are in (from the MEDX which is only the hospital cover to the PINNACLE, which is an executive option and very comprehensive in benefits).
- All savings accounts in the CompCare plans carry forward positive balances from the previous year, and you can use the funds as and when needed.
- CompCare provides cover for adventure sporting activities, a benefit which is usually excluded by many schemes.
- The DYNAMIX and PINNACLE options provide the Above Threshold Benefit, which allows you to continue claiming benefits even after you have depleted your annual Day-to-Day Benefit allocation
- CompCare is associated with reputable healthcare institutions like Netcare and Dis-Chem.
Competitive disadvantages of the CompCare Wellness medical scheme
Pre-authorisation is mandatory for all non-emergency hospital admissions. It doesn’t matter which plan you are in, not getting authorisation may result in co-payments.
Even though some CompCare plans state that you can use any private hospital, non-Netcare hospitals may result in copayments, which are usually never below R10 000.
Getting medical insurance is of the utmost importance to your health. Even if you do not have any underlying health complications/illnesses, getting health insurance (at the very least hospital insurance) will protect you in the event of an unexpected event such as hospitalization.
CompCare is among the most reputable health insurers in South Africa, alongside health cover providers such as Genesis Medical Scheme and Bestmed. CompCare can get you covered with an appropriate plan that will suit your needs and pockets. The scheme has varied plans, so you can surely get what you are looking for.