Choosing the Right Medical Scheme: A Broker's Guide to Advising Clients

What Clients Expect from You

1. Expert Knowledge - Understanding of all major schemes and their nuances
2. Objective Advice - Recommendations based on their healthcare and affordability needs
3. Simplification - Making complex information understandable
4. Comparison - Comparing multiple suitable options
5. Ongoing Support - Servicing beyond the sale
6. Claims assistance - Assistance with expensive claims

Your Value Proposition

• Save clients hours of research
• Access to professional comparison tools
• Understanding of benefit fine print
• Navigation of claims and admin issues
• Year-end reviews and optimisation
• Advocacy with schemes when problems arise

Step 1: Demographic Information

Basic Details:

• Main member age
• Spouse/partner age
• Number and ages of dependents
• Employment status (employed, self-employed, retired)
• Location (province and city)
• Monthly budget range for medical scheme
• Previous medical scheme membership

Why This Matters:

• Age affects contribution costs and risk profile
• Children have different needs at different ages
• Location determines hospital and doctor network access
• Employment impacts eligibility for group schemes
• Late Joiner Penalties for lapses in membership may apply

Step 2: Health Status Assessment

Current Health:

• Any chronic conditions (diabetes, hypertension, asthma, etc.)?
• Regular medications?
• Any disabilities or special needs?
• Recent health events or diagnoses?
• Mental health support needs?

Family Health History:

• Hereditary conditions to watch for?
• Cancer or cardiac history?
• Pregnancy plans?

Why This Matters:

• Chronic conditions require specific coverage and PMB protection
• Some schemes have better chronic disease management programs
• Maternity benefits vary significantly
• Family history may influence risk tolerance

Step 3: Healthcare Usage Patterns

Historical Usage:

• How many times did you see a GP last year?
• Any specialist visits?
• Emergency room visits?
• Planned procedures or operations?
• Dental and optical usage?
• Alternative therapy use (physio, chiropractor)?

Preferred Providers:

• Do you have preferred doctors or specialists?
• Preferred hospital?
• Pharmacies used?
• Need for specific provider networks?

Why This Matters:

• High GP users need good day-to-day benefits
• Specialist-heavy users may need higher overall cover
• Provider preferences must align with scheme networks
• Usage patterns predict future needs

Step 4: Risk Profile and Priorities

What's Most Important to You?

Rank these priorities (1-5 scale):

• Comprehensive hospital cover
• Day-to-day benefits (GP, dentist, optometry)
• Chronic medication coverage
• Low monthly contribution
• Private hospital access
• Specific doctor/hospital access
• International travel cover
• Maternity benefits
• Cancer and oncology cover
• Wellness and preventive care programs

Risk Tolerance:

• "Are you comfortable with a savings account that could deplete?"
• "Would you accept a network plan to reduce costs?"
• "Can you afford co-payments if necessary?"

Step 5: Budget Reality Check

Affordability Questions:

• "What's your realistic monthly budget for medical scheme?"
• "Can you allocate 10-15% of household income to health cover?"
• "Would you rather reduce day-to-day benefits or hospital cover if budget is tight?"
• "Can you build an emergency fund for out-of-pocket costs?"

Budget Bracket Classification:

• Entry Level: R1,500 - R2,500 pm
• Mid-Range: R2,500 - R5,500 pm
• Upper Mid: R5,500 - R9,000 pm
• Premium: R9,000+ pm

1. Hospital Cover (Most Critical)

What to Evaluate:

• In-Hospital Benefits: 100%, 200%, 300% of scheme tariff?
• Private vs. Semi-Private: Single or shared rooms?
• Hospital Network: All private hospitals or network only?
• Co-Payments: Any sub-limits or co-payments on procedures?
• PMB Coverage: Emergency treatment, 270 diagnoses, chronic conditions
• Oncology: How comprehensive is cancer treatment cover?
• Are Specialists covered at the Scheme Rate or above
• ICU and High Care: Limits or unlimited?
• Maternity: Hospital cover and neonatal care?

Red Flags:

• Hospital network too restrictive for client's area
• Sub-limits on major procedures
• Co-payments on certain procedures
• State hospitals or limited network hospitalss

1. Day-to-Day Benefits

Savings Account Options:

• Medical Savings Account (MSA) amount
• Depletion rate based on usage
• Rollover rules
• Benefits paid from Risk when MSA is depleted

Above Threshold Benefits:

• Annual threshold Benefit (ATB) amount
• What's covered above threshold?
• Limits on GP visits, specialists, etc.

Specific Day-to-Day Benefits:

• GP consultations (in-hospital vs. out-of-hospital)
• Specialist consultations
• Dentistry (basic and specialised)
• Optometry
• Acute medication
• Radiology and pathology
• Physiotherapy and alternative therapies

For Hospital-Only Plans:

• What day-to-day expenses will be out-of-pocket?
• Can client afford routine care costs?

1. Chronic Medication (PMB and Non-PMB)

Key Questions:

• Are client's chronic conditions on the CDL (Chronic Disease List)?
• What's the chronic medication protocol?
• Formulary restrictions?
• Disease management programs available?
• Generic vs. originator medication policies?

PMBs (Prescribed Minimum Benefits):

All schemes must cover 27 chronic conditions:

• Addison's disease
• Asthma
• Bipolar mood disorder
• Bronchiectasis
• Cardiac failure
• Cardiomyopathy
• Chronic obstructive pulmonary disorder
• Chronic renal disease
• Coronary artery disease
• Crohn's disease
• Diabetes insipidus
• Diabetes mellitus Type 1 & 2
• Dysrhythmia
• Epilepsy
• Glaucoma
• Haemophilia
• HIV/AIDS
• Hyperlipidaemia
• Hypertension
• Hypothyroidism
• Multiple sclerosis
• Parkinson's disease
• Rheumatoid arthritis
• Schizophrenia
• Systemic lupus erythematosus
• Ulcerative colitis

1. Networks and Provider Access

Hospital Networks:

• Full private hospital access vs. network hospitals
• Geographic coverage (especially if client travels)
• Preferred hospitals in network?
• Quality tier of network hospitals

Doctor Networks:

• GP networks (Intercare, Dis-Chem Clinics, Clicks Clinics, etc.)
• Specialist panels
• Can client keep current doctors?
• Network limitations and out-of-network costs

Pharmacy Networks:

• Designated pharmacy benefits
• Courier medication services
• In-hospital pharmacies

Pros of Networks:

• Lower contributions
• Coordinated care
• Better cost control

Cons of Networks:

• Limited provider choice
• May require changing doctors
• Out-of-network penalties
• Geographic restrictions

1. Financial Strength and Sustainability

Solvency Ratios:

• Check scheme's solvency ratio (minimum 25%)
• Higher is better (indicates financial stability)
• Review trends over past 3-5 years

Membership Numbers:

• Growing, stable, or declining?
• Large schemes often have better negotiating power
• Small schemes may have more personalized service
• Scheme growth, pensioner percentage and average age of members also affects value for money

Administrator Reputation:

• Discovery, Momentum, Medscheme, etc.
• Admin efficiency affects client experience
• Claims processing speed
• Customer service quality

1. Value-Added Benefits

Wellness Programs:

• Vitality, Multiply, etc.
• Gym benefits
• Preventive care incentives
• Preventative screening programs

Additional Benefits:

• Travel insurance
• Emergency medical evacuation
• Gap cover arrangements
• Flu vaccinations
• Baby packs and maternity support

Digital Tools:

• Mobile apps
• Online claims submission
• Telemedicine services
• Health risk assessments

Step 1: Shortlist Suitable Options

Based on needs analysis, identify 3-5 options that:

• Fit the budget (or slightly above with justification)
• Cover priority needs
• Provide adequate hospital cover
• Include client's preferred providers
• Offer good value for money

Balancing Act:

• Best Option: Meets all needs, slightly above budget
• Value Option: Best balance of cover and cost
• Budget Option: Minimum acceptable cover within budget

Step 2: Detailed Comparison

Use professional comparison tools (such as Brokertools) to compare across:

• Risk and Hospital Benefits: 10-15 criteria
• Day-to-Day Benefits: 10-15 criteria
• Chronic Medication: 5-10 criteria
• Network and Access: 5-8 criteria
• Additional Benefits: 5-10 criteria
• Loyalty programmes
• Financial and demographic information: 5-7 criteria

Since medical schemes are complex, it would require at least 50 comparison criteria to provide clients with objective advice

Step 3: Present Options to Client

Effective Presentation Structure:

1. Recap Needs: "Based on our discussion, your priorities are..."
2. Shortlist Introduction: "I've identified three options that meet your needs..."
3. Option-by-Option Review:

• Scheme and plan name
• Monthly contribution
• Key benefits highlight
• What it does well
• Potential limitations
• Who it's best suited for

1. Side-by-Side Comparison: Visual comparison of key features
2. Real-World Scenarios:

• "If you needed a knee replacement, here's how each would cover it..."
• "Based on your GP visit frequency, here's how day-to-day would work..."

1. Total Cost Analysis:

• Monthly contribution
• Estimated out-of-pocket costs
• Total annual healthcare spend

Step 4: Make Your Recommendation

Be Clear and Confident:

"Based on everything we've discussed, I recommend [Option Name] because..."

Reasoning Should Include:

• How it addresses their specific priorities
• Why it's better value than alternatives
• What makes it suitable for their circumstances
• How it protects against their key risks

Acknowledge Trade-Offs:

"While this option is R500 more per month than the budget option, it provides [X benefit] which is important because..."

Step 5: Handle Objections and Questions

Common Objections:

"It's too expensive"

• Show value comparison (what you get for the extra cost)
• Calculate cost per day
• Compare to other expenses (DSTV, gym, eating out)
• Discuss consequences of under-insurance
• Explore downgrade options if truly unaffordable

"I'm young and healthy, do I need this much cover?"

• Emphasise medical scheme as insurance, not investment
• Give examples of unexpected events (accidents, appendicitis, etc.)
• Discuss cost of even a simple surgery without cover
• Mention late joiner penalties if they delay

"Can I start with basic and upgrade later?"

• Explain waiting periods on upgrades (3 months general, 12 months PMB conditions)
• Risk of diagnosis during waiting period
• Potential pre-existing condition exclusions
• Sometimes yes, but quantify the risks

"What about medical scheme gaps?"

• Explain gap cover options
• Show actual gap costs on specific procedures
• Discuss co-payments vs. gaps
• Some schemes have better tariff rates (less gap)

"My friend says their scheme is better"

• Acknowledge different needs require different solutions
• "What works for them may not be optimal for you because..."
• Redirect to their specific needs and priorities
• Offer to review their friend's scheme if they'd like

Major Open Schemes Overview

Discovery Health Medical Scheme

• Strengths: Innovative products, strong hospital networks, Vitality wellness, excellent technology
• Considerations: Premium pricing, complex plan structure, Vitality can be overwhelming for some
• Best For: Health-conscious clients, comprehensive cover seekers, technology adopters

Momentum Health

• Strengths: Good value, extensive hospital access, Multiply rewards, strong chronic management
• Considerations: Network plans have limitations, some benefit restrictions
• Best For: Value seekers, families, clients wanting wellness rewards

Bonitas Medical Fund

• Strengths: Competitive pricing, good entry-level options, standard hospital access
• Considerations: Limited value-adds, conservative approach
• Best For: Budget-conscious clients, straightforward cover needs

Fedhealth

• Strengths: Member-owned, strong solvency, good value, member loyalty programs
• Considerations: Smaller scheme, regional variations
• Best For: Clients valuing member-ownership, established families

Bestmed

• Strengths: Very competitive pricing, decent benefits at lower cost points
• Considerations: Stricter networks on some plans, limited frills
• Best For: Price-sensitive clients, basic but solid cover

Medihelp

• Strengths: Affordable, good entry-level hospital plans, simple structure
• Considerations: Limited comprehensive options
• Best For: Young individuals, budget-conscious families

(Expand with additional schemes relevant to your client base)

When NOT to Recommend a Specific Option:

1. Budget Mismatch: Client can't realistically afford the contribution
2. Network Misalignment: Preferred providers not in network
3. Chronic Condition Concerns: Medication not on formulary
4. Geographic Limitations: No network hospitals in client's area
5. Over-Insurance: Client paying for benefits they'll never use
6. Under-Insurance: Hospital cover insufficient for client's risk profile
7. Scheme Instability: Declining membership or solvency concerns
8. Complex for Client: Product too complicated for client to understand and use effectively

Young Single Professional or student

Typical Needs:

• Basic but solid hospital cover
• Minimal day-to-day (low GP usage)
• Trauma and emergency focus
• Affordable

Recommended Approach:

• Hospital plan or hospital plan with small savings account
• Network plan to reduce cost
• Emphasize accident and emergency cover
• Keep budget reasonable (R1,500 - R2,500)

Suitable Options:

• Entry-level comprehensive plans
• Pure hospital plans with good networks
• Network hospital plans

Young Family with Children

Typical Needs:

• Pediatric care
• Maternity (if planning children)
• Higher GP usage
• Vaccinations and baby health visits
• Family dentistry and optometry
• Affordability

Recommended Approach:

• Comprehensive plan with good day-to-day cover
• Savings account to cover routine pediatric care
• Maternity benefits if needed
• Above-threshold benefits for family claims

Suitable Options:

• Mid-range comprehensive plans
• Plans with family-friendly benefits
• Schemes with good chronic medication formularies

Middle-Aged Professionals

Typical Needs:

• Comprehensive hospital cover
• Specialist access
• Chronic medication (increasingly common)
• Cancer and major illness cover
• Private hospitals and doctors

Recommended Approach:

• Higher-tier comprehensive plans
• 200-300% hospital cover
• Good above-threshold benefits
• Chronic medication priority
• Consider gap cover

Suitable Options:

• Upper-tier comprehensive plans
• Executive plan levels
• Schemes with strong oncology benefits

Retirees

Typical Needs:

• Extensive chronic medication
• Frequent specialist visits
• High hospital utilization risk
• Affordability on fixed income
• Established doctor relationships

Recommended Approach:

• Focus on chronic medication cover
• Excellent hospital benefits
• Keep day-to-day reasonable
• Provider network must include current doctors
• Consider pensioner-specific plans

Suitable Options:

• Senior/pensioner-specific plans
• Comprehensive plans with strong chronic benefits
• Schemes with good hospital and PMB cover

Self-Employed/Entrepreneurs

Typical Needs:

• Flexible benefits
• Income protection consideration
• Value for money
• Comprehensive cover but cost-conscious

Recommended Approach:

• Balance cover and cost carefully
• Hospital plan plus separate savings may work
• Emphasize disability and income protection
• Network plans can work if location-stable

Suitable Options:

• Mid-range comprehensive
• Hospital plans with flex benefits
• Value-focused schemes

High-Income Executives

Typical Needs:

• Best available cover
• Private specialists and facilities
• International cover
• Convenience and service
• Wellness programs

Recommended Approach:

• Top-tier comprehensive plans
• Unlimited or very high hospital benefits
• Best day-to-day cover
• Value-adds like Vitality/Multiply
• Consider gap cover at higher levels

Suitable Options:

• Executive/presidential plans
• Top-tier Discovery, Momentum, etc.
• Schemes with concierge services

When to Recommend Switching Schemes

Good Reasons:

• Significant cost savings (>15%) with comparable cover
• Better benefits for same price
• Current scheme has declined in benefits
• Client's needs have changed (new chronic condition, pregnancy, etc.)
• Provider access issues on current scheme
• Poor service experience on current scheme
• Better technology and user experience elsewhere

Proceed with Caution:

• Client has chronic conditions (formulary changes)
• Mid-year switch (timing and waiting periods)
• Client is happy but broker can earn higher commission elsewhere
• Marginal benefit differences
• Frequent switcher (stability matters)

The Three-Month Rule

Critical Consideration for Chronic Conditions:

• Switching schemes may trigger 3-month general waiting period
• Medication must continue during transition
• Ensure new scheme covers condition and medication
• Confirm formulary includes client's specific medication
• Plan switch timing carefully

Switching Process Checklist

• Confirm client understands benefits and costs of new scheme
• Complete comprehensive Record of Advice
• Submit application well before deadline (mid-November latest)
• Confirm acceptance from new scheme
• Cancel old scheme (only after new scheme confirms coverage)
• Transfer chronic medication authorisations
• Update payment details
• Confirm coverage start date (January 1)
• Follow up in January to ensure smooth transition

1. Commission-Driven Recommendations: Recommending based on your commission, not client needs
2. One-Size-Fits-All: Using same recommendation for every client
3. Insufficient Needs Analysis: Not digging deep enough into client circumstances
4. Overcomplicating: Confusing clients with too much information
5. Ignoring Budget Reality: Recommending unaffordable options
6. Neglecting Networks: Not verifying provider access
7. Poor Documentation: Incomplete Records of Advice
8. Overselling: Making promises schemes can't keep
9. Underselling: Not explaining value of comprehensive cover
10. No Follow-Up: Abandoning clients after the sale

Essential Broker Tools

Comparison Software:

• Professional tools like Brokertools for side-by-side comparison
• 55+ criteria comparison capability
• Real-time rate updates
• Professional quotation generation

Scheme Resources:

• Benefit brochures and guides
• Formulary lists
• Hospital and network directories
• Clinical protocols

Regulatory Resources:

• Council for Medical Schemes Annual Report and Website
• PMB regulations
• FAIS compliance requirements
• Industry updates

Building Your Knowledge Base

Continuous Learning:

• Attend scheme update sessions
• Read industry publications
• Join broker networks and forums
• Complete CPD requirements
• Follow regulatory changes

Client Insights:

• Track common questions and objections
• Learn from client feedback
• Document successful solutions
• Analyse retention and satisfaction

Choosing the right medical scheme is both an analytical exercise and a relationship-building opportunity. The best brokers combine:

• Technical Expertise: Deep knowledge of schemes, benefits, and regulations
• Analytical Skills: Ability to compare and evaluate complex information
• Communication Skills: Making the complex simple and relatable
• Empathy: Understanding client fears, priorities, and constraints
• Ethics: Always putting client needs first
• Service Excellence: Supporting clients beyond the initial sale

By following a structured needs analysis process, comparing comprehensively, and making well-reasoned recommendations, you'll build trust, deliver value, and create lasting client relationships.

Remember: The best medical scheme for your client is the one that meets their needs, fits their budget, and gives them peace of mind. Sometimes that's not the most comprehensive option or the cheapest one—it's the right balance for their unique circumstances.

Ready to elevate your medical scheme recommendations and client servicing abilities? Discover how Brokertools can streamline your comparison process with comprehensive benefit analysis across 55+ criteria, professional quotation generation, and FAIS-compliant documentation. Contact us today for a demonstration.