It’s an all too familiar scenario.
August hits, the last of the flu season still abounds, and you get ill; but instead of your pharmacist packing and handing over your prescribed medication with a smile, you are hit with these horrifying words: “Your medical savings have run out, shall we make a cash payment for you?”
You weren’t prepared to fork-out a small fortune for cough syrup and pain tablets. Moreover, you weren’t even aware your day-to-day benefits were depleted.
“Members are often misinformed about benefits, or think they have a specific benefit for medication, therapy or a device when it is covered from their savings. For example a pair of glasses with an expensive designer frame will be paid from day-to-day savings, and can quickly deplete a savings account,” Jeremy Yatt, Fedhealth’s principal officer, said.
According to a financial planning expert, Maya Fischer-French, by August every year, “more than half of medical scheme members will have run out of day-to-day savings which means that doctor visits and medication would have to be paid for out of your own pocket.”
To avoid unexpected medical expenses such as these, Yatt said the key was to “know your specific option inside out” and to use the network providers with whom your scheme has negotiated.
Gerhard van Emmenis, the acting principal officer of Bonitas Medical Fund, said another key misconception about the savings account, was that it would cover “all your claims”.
“We strongly urge members to use their savings cleverly so that they can get maximum value for money,” he said.
Expanding on this, Van Emmenis suggests getting the flu vaccine as a means to save on using up one’s savings.
“About 14% of absenteeism in corporate South Africa is related to influenza. Although the vaccine isn’t perfect and there is no 100% guarantee, it is the best way to lessen your chances of getting it..
“Pharmacists too can provide sound medical advice on problems such as rashes, colds or illnesses that are not severe. Consider using generic medicine, which is cheaper,” he said.
Yatt said paying smaller amounts for medication or treatments from your pocket where possible was also a valuable way to keep your savings for greater medical expenses.
Van Emmenis also suggests the following ways to stave-off fund depletion.
* Use partner networks: Medical schemes negotiate preferential rates with these partners. This means if you use a network hospital, doctor or pharmacy you will not be charged more than the rate agreed with the scheme.
This way you avoid co-payments, deductibles and additional out-of-pocket expenses.
* Find a GP on your medical aid’s network: Using network doctors is an invaluable tool to make your medical aid last longer. It means that doctors can’t charge you more than a specific amount.
* Register all chronic diseases: If you’re on regular medication to treat a chronic illness - such as diabetes, hypertension or hypothyroidism - you could qualify for chronic medication benefits. This means that your medical scheme pays for those medicines out of the risk portion of your medical aid and not your medical savings account. All you need to do is register your condition as chronic.
* Make use of preferred providers: Medical schemes often have providers that are contracted to them. Members are then given better rates for specific benefits.
* Use formulary meds: All medical schemes have a list of medication they cover called a formulary. Another way to avoid co-payments and out-of-pocket expenses is to ensure your doctor treats you with medication listed on your plan's specific formulary.
Where applicable, you can also use a designated service provider to obtain your medicine and stretch your benefits.
* Managed care benefits: Some schemes offer preventative care benefits, which are paid from the risk portion of your medical scheme and are not funded from your savings account. This includes oncology, HIV and diabetes management programmes.
* Don’t be uninformed: Take the time to read the information sent to you by your medical scheme or broker. Read the fine print and understand the scheme’s rules.