How to Conduct Year-End Medical Scheme Reviews

1. Gather Scheme Information

Brokertools summarises the medical scheme benefits within 48 hours after the scheme launches the product information. The scheme brochures are also loaded onto the document repository.

• View the benefit summaries and scheme brochures for the coming year
• Note contribution increases for each scheme
• Identify benefit enhancements or reductions
• Review network changes (hospital lists, doctor networks)
• Check for new scheme options or product launches
• Note any scheme mergers or closures

1. Segment Your Client Database

Prioritize reviews based on:

High Priority:

• Clients with significant contribution increases (>10%)
• Clients on schemes or options with major benefit changes
• Clients who have logged multiple claims queries
• New clients (first year-end with your FSP)
• High-value and corporate clients
• Clients with chronic conditions

Medium Priority:

• Stable clients with moderate increases
• Clients who've been on same option 3+ years
• Young families with changing needs

Lower Priority:

• Recently reviewed and happy clients
• Clients with minimal utilization
• Budget-constrained clients on entry-level options

1. Prepare Your Tools

• Check whether the new benefit information is updated on Brokertools
• Check whether the option change forms and application forms are available in the document repository
• Prepare year-end review templates within the Brokertools YER Wizard
• Set up appointment scheduling system
• Brief your team on new scheme changes
• Prepare communication materials (emails, SMS templates)
• Ensure that Brokertools CRM is updated with latest client information

Step 1: Initial Client Outreach (September)

Communication Methods:

• Email campaigns announcing year-end review season
• SMS reminders
• Phone calls to priority clients
• Social media posts
• WhatsApp Business messages (where appropriate)

Sample Email Template:

Subject: Your 2026 Medical Scheme Year-End Review

Dear [Client Name],

As we approach the end of the year, medical schemes will be announcing their (next year) benefits and contribution changes. This is the perfect time to review your current coverage and ensure you and your family have the best possible protection at the right price.

Over the next few weeks, I'll be conducting personalized reviews for all my clients. I'd like to schedule a 30-minute consultation with you to:

• Review your (current year) benefit utilisation
• Discuss any changes to your family's health needs
• Present your scheme's (next year) changes
• Compare alternative options if beneficial
• Ensure you are taking advantage of your medical scheme tax credit

Please reply to this email or call me on [number] to schedule your review.

OR

Over the next few weeks, we will be sending you an electronic link which you can use to:

• Compare your current medical scheme option with next year's option
• View and compare upgrade and downgrade options of your chosen medical scheme
• Choose your option for next year.

In making your selection, please take the following into consideration:

• Your benefit utilisation over the past year
• Any changes to your family's health needs
• Any significant benefit changes to your current option
• The benefits and contributions of other options available to you.

Please reply to this email or call us on [number] should you require personalised assistance or advice in performing your review.

Looking forward to connecting with you.

Best regards,

[Your Name]

[FSP Number]

Step 2: Pre-Review Data Gathering

Before meeting with the client, gather:

From Medical Schemes:

• Current scheme profile report with up-to-date client information
• Claims history and benefit utilisation (if available)
• Savings account balance
• Chronic medication authorisation status
• Hospital network utilisation.

From Client Records in CRM:

• Original needs analysis and ROA
• Family composition
• Previous concerns or preferences
• Communication history
• Special requirements or conditions

Analysis steps:

• Are they over-insured or under-insured?
• Is their savings account depleted every year?
• Are they using out-of-network providers frequently?
• Have they had gaps in cover or shortfalls?
• What was their total out-of-pocket spend?
• Are there any in-hospital expenses that is foreseen?

Step 3: The Review Consultation

Opening the Meeting (5 minutes)

1. Thank client for their time
2. Outline meeting agenda
3. Confirm any changes to family circumstances
4. Ask about health events in the past year

Current Scheme Performance Review (10 minutes)

Benefits utilised:

• "Let's look at how you used your medical aid this year..."
• Review major claims (hospitalisations, procedures)
• Chronic medication usage
• Day-to-day benefits consumption
• Out-of-pocket expenses

Red Flags to Discuss:

• Frequent out-of-network provider use
• Savings account depleted early in the year
• Shortfalls or co-payments on major claims
• Unused benefits (e.g., dental, optical)
• Sub-limit exhaustion

Needs Assessment Update (5 minutes)

Ask about:

• Any new diagnoses or chronic conditions?
• Planned procedures or treatments for next year?
• Are your regular doctors and specialists still preferred?
• Hospital preferences changed?
• Any family additions or changes?
• Budget constraints or concerns?
• Are you happy with current scheme administration and service?

Presenting next year Changes (5 minutes)

For Current Scheme:

• New contribution amount (percentage increase)
• Benefit changes (improvements or reductions)
• Network changes
• New rules or waiting periods
• Admin changes

Present this objectively, highlighting both positives and concerns.

Alternative Options Analysis (10 minutes)

When to Present Alternatives:

• Contribution increase is above inflation
• Benefits have been reduced
• Client expressed dissatisfaction
• Better value available elsewhere
• Life stage has changed (e.g., young family now has teenagers)
• Affordability concerns

How to Present:

1. Start with similar options on current scheme
2. Then compare to other schemes
3. Use side-by-side benefit comparison from Brokertools
4. Highlight key differences
5. Show total cost comparison (contribution + estimated out-of-pocket)
6. Discuss network and provider access
7. Check compared options Benefit Richness scores

Key Comparison Points:

• Hospital plan benefits
• Day-to-day benefits and savings accounts
• Chronic medication coverage
• Maternity benefits (if relevant)
• Oncology and specialised treatment
• Threshold and above-threshold benefits
• Overall network
• Premium difference
• Administration and service quality

Recommendation (3 minutes)

Provide clear recommendation with reasoning:

• "Based on your usage and needs, I recommend..."
• "This option will save you R[X] per month while maintaining..."
• "Although this is R[X] more expensive, it provides..."

Be honest about pros and cons.

Handling Objections (2 minutes)

Common objections:

• "It's too expensive" - Show value, discuss downgrades, or consider day-to-day reductions
• "I don't want to change" - Respect loyalty but quantify the cost of staying
• "I need to think about it" - Provide written summary, set follow-up date
• "My employer provides my medical aid"- Discuss voluntary benefits or family coverage

Step 4: Documentation and Follow-Up

Immediately After Meeting:

• Complete Record of Advice
• Update CRM with meeting notes
• Send summary email with recommendations
• Attach benefit comparisons and quotations
• Set follow-up tasks.

Follow-Up Schedule:

• Day 3: Quick check-in SMS/email
• Week 2: If no response, phone call
• Week 3: Final reminder before deadlines
• After decision: Confirmation and welcome pack

Scenario 1: Client Wants to Downgrade Due to Cost

Approach:

1. Acknowledge budget concerns empathetically
2. Review actual benefit usage
3. Calculate real cost difference
4. Identify "nice-to-have" vs "must-have" benefits
5. Present safer downgrade options
6. Warn of risks (network limitations, co-payments)
7. Document decision thoroughly

Options to Consider:

• Lower plan on same scheme
• Scheme with better entry-level options
• Hospital plan with savings account add-on
• Network plans with lower premiums

Scenario 2: Client with Chronic Condition

Critical Considerations:

• PMB coverage and formularies
• Chronic medication protocols
• Specialist network access
• Disease management programs
• Pre-authorization requirements
• Three-month switching rule implications

Best Practice:

If recommending a switch, confirm:

• New scheme covers their condition as PMB
• Medicine on new scheme formulary
• Specialists and treating doctors in network
• Seamless transition of chronic medication authorization

Scenario 3: Young Healthy Client ("I Never Claim")

Education Opportunity:

• Medical aid is insurance, not a savings plan
• Peace of mind value
• Major medical risk (accidents, emergency surgery)
• Preventive care benefits
• Tax credit benefits
• Show examples of unexpected claims

Options:

• Hospital plans with low day-to-day benefits
• Network plans with reduced premiums
• Income-based options

Scenario 4: Client Switching from Employer Scheme

Unique Considerations:

• Loss of group subsidy
• Need for comprehensive comparison
• Budget shock (full premium)
• Waiting periods on new scheme
• Late joiner penalties if applicable
• Cover gap risks

September

• Gather scheme information
• Prepare database and tools
• Begin priority client outreach
• Schedule appointments at high value and corporate clients

October

• Conduct bulk of client reviews
• Follow up on pending decisions
• Handle queries and objections
• Process applications for changes

November

• Final push for undecided clients
• Process late applications
• Confirm all switches and changes
• Handle admin and paperwork

December

• Confirm coverage start dates
• Welcome new clients
• Thank retention clients
• Prepare for January queries

January

• Monitor activation of new policies
• Resolve teething issues
• Check chronic medication authorizations
• Follow up on satisfaction

1. Starting Too Late - Begin in September, not November
2. Generic Communication - Personalize based on client needs
3. Pushing Switches - Recommend what's genuinely best
4. Incomplete ROAs - Document everything properly
5. Ignoring Satisfied Clients - They need reviews too
6. Poor Follow-Up - Set systematic reminders
7. Not Setting Expectations - Explain deadlines and timelines clearly
8. Forgetting Dependents - Children aging out at 21 or 26
9. Overlooking Tax Implications - Discuss medical aid credits
10. No Post-Switch Support - Help with January admin

Brokertools Advantages:

Preparation Phase:

• Import client data from scheme profile reports
• Automatically flag clients with high increases
• Generate pre-populated comparison reports

During Reviews:

• Real-time benefit comparison across 55 criteria
• Professional quotations generated instantly
• Document repository for quick brochure access
• Contribution calculator for budgeting

Follow-Up:

• CRM tracking of review status
• Automated reminder communications
• Query management and resolution tracking
• Reporting on review completion rates

Key Metrics to Track:

• Percentage of clients reviewed
• Retention rate
• Upgrade/premium increase rate
• New business generated
• Average time per review
• Client satisfaction scores
• Compliance (ROAs completed)

Set Goals:

• Review 95%+ of active clients
• Retain 90%+ of book
• Generate X new applications
• Complete all reviews by November 15

Phone Script for Booking Appointments:

"Hi [Client Name], this is [Your Name] from [FSP Name]. I hope you're well.

I'm calling because it's year-end review time, and medical schemes are announcing their 2027 changes. I want to make sure you're on the best option for your family's needs and budget.

Can we schedule 30 minutes in the next two weeks? I'll review your current coverage, show you what's changing next year, and make sure you're getting the best value. I have availability on [Day 1] at [Time] or [Day 2] at [Time]. What works better for you?"

Summary Email Template:

Subject: Summary of Your Year-End Medical Scheme Review

Dear [Client Name],

Thank you for taking the time to meet with me today to review your medical aid coverage for 2027.

Summary of Discussion:

• Current Option: [Scheme and Option Name]
• 2026 Contribution: R[Amount]
• 2027 Contribution: R[Amount] ([X]% increase)
• Key Benefit Usage: [Summary]

My Recommendation:

[Clear recommendation with reasoning]

Next Steps:

[Action items and deadlines]

Attached Documents:

• Benefit comparison report
• Quotation for recommended option
• 2027 benefit brochure

If you'd like to proceed with [recommendation], please respond to this email by [date], and I'll handle all the paperwork.

If you have any questions or would like to discuss further, please don't hesitate to contact me.

Best regards,

[Your Name]

[Contact Details]

[FSP Number]

Conducting thorough year-end medical scheme reviews is both a regulatory requirement and a business opportunity. By following a systematic process, leveraging technology, and putting client needs first, you can deliver exceptional value during this critical period.

Remember: year-end reviews aren't just about switching clients—they're about ensuring every client has the right coverage, understands their benefits, and feels valued by your service.

Ready to streamline your year-end reviews? Discover how Brokertools can help you conduct efficient, compliant, and professional reviews for all your clients. Contact us today for a demonstration.