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What to know about medical scheme members

Dec 26 2016 14:45
Susan Erasmus

The profile of members on your medical scheme can have quite an effect on your contributions, benefits and the health of your scheme. Here’s more about what you should know:

You join a medical scheme, but you don’t really know much about the other people who are also members. Their state of health, claims pattern, age and number of dependants can have a big effect on you. Check out the facts below to get a clearer picture of the profile of members of SA medical schemes.

Average age

• The average age of members belonging to open schemes in South Africa in 2015, was 33.8 years. This was up from 33.6 years in 2014.

• On restricted schemes the average age was 30.5 years in 2015 – up from 30.2 years in 2014.

• One of the main reasons why restricted schemes have a lower average age, is that young and healthy employees are often obliged to join restricted schemes as part of their employment contracts. On the open market, there is no such obligation.

• For every year’s increase in average age, the average claim per member rises by 2%. So if the average age rises by two years, and the number of members stay the same, the claims will be 4% higher.

Pensioner ratio

• Pensioners tend to be high claimers. On the open schemes, in 2015, 8.8% of members were pensioners, up from 8.5% in 2014.

• On restricted schemes these numbers were respectively 6.1% (2015) as opposed to 5.9% (2014).

• KeyHealth (open) and Transmed (restricted) have the highest pensioner ratios of SA medical schemes.

• The number of pensioners on all schemes in SA is on the increase, but particularly so on open schemes.

• To combat these costs, schemes have to either increase their contributions, or cut their benefits to all members.

Family size

• This refers to the average number of dependants that each principal member has registered on their scheme.

• This number has been dropping over the last 15 years, partially as a result of the high cost of medical scheme membership.

• It is thought that the falling away of employer subsidies on many restricted schemes has also contributed to the reduction in the number of dependants.

• The average number of dependants per principal member on all schemes is 2.23 in 2015. This is down from 2.25 in 2014.

General facts on SA medical scheme members

• There are 3.95 million principal members on medical schemes in South Africa.

• These principal members have a total of 8.81 million beneficiaries (both adult and child dependants).

• The number of principal members on all schemes in SA has increased marginally from 2014 to 2015 by 0.8%, but scheme membership remains more or less static.

• Of those belonging to schemes, 58.9% of principal members belonged to open schemes at the end of 2015 and 41.1% belonged to restricted medical schemes.

• In 2015 there were three open medical schemes and 28 restricted schemes with fewer than 6000 principal members. The three open schemes are Cape Medical Plan, Makoti Medical Scheme and Suremed.

• The biggest open scheme in SA, Discovery Health Medical Scheme, covers over 1.4 million lives.

• The Government Employees Medical Scheme (GEMS) lost 12 021 principal members in 2015.

(Information from the Diagnosis 2016/2017 published by the team from Alexander Forbes Health)

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