Medical Aid Exhausted – Insufficient Funds

Out-of-hospital medical aid benefits are not unlimited and most members would have experienced a situation where their medical aid funds were exhausted. Once your funds are depleted for the year, you will have to wait for the following year in order to qualify for the new benefit allocation. This is every medical aid member’s nightmare especially if it occurs early in the year but with careful planning, you can avoid this scenario.

Out-of-Hospital, Day-to-Day Medical Aid Benefits

Your medical aid fund allocation is divided between a day-to-day or out-of-hospital benefit, chronic cover and in-hospital benefit. In most instances, it is highly improbable that you will deplete your in-hospital benefit and with prescribed minimum benefit (PMB) regulations, your chronic cover will be ongoing for the entire year for 25 major chronic conditions. Both the in-hospital and chronic cover is closely managed by your medical aid.

However your out-of-hospital benefit is under your control and if it is used recklessly, you will most probably exhaust these funds before the year end. Out-of-hospital medical aid benefits cover consultation fees, acute medicines, auxillary therapies like physiotherapy, blood tests, x-rays and other investigations as well as optometry benefits (for spectacles and contact lens). This cover is not available if you are on a medical aid hospital plan.

Insufficient Medical Funds

Once you have used your entire out-of-hospital benefit, you will not be able to access medical aid funds for related services. Some medical aids have certain options where they will cover your remaining medical expenses for the year if you meet with certain conditions. But in most cases, once your medical aid reports that there is insufficient funds, it means your medical aid is exhausted for the year.

If your medical aid does not pay a doctor or medical service provider for your last consultation or treatment, then you are liable for the bill. You will have to settle the service provider out of your own pocket.  The fact that you will continue to pay your medical aid premiums for the remainder of the year does not mean that you still have access to out-of-hospital funds once your medical aid is exhausted.

Managing Your Day-to-Day Medical Expenses

It is important to remember that the out-of-hospital benefit is either limited to your savings or a pre-defined day-to-day amount that is made available from the beginning of the year. This amount is essentially your annual budget for medical expenses that do not qualify as chronic cover or in-hospital benefits. In order for this amount to sustain you till the year end, you will have to manage your daily medical expenses wisely.

Some tips for saving out-of-hospital benefits :

  • Pay cash for medical services that discount non-medical aid payments. Many medical practitioners will charge you a lower rate for a consultation and medicines  if you pay cash.
  • Avoid shopping on your medical aid. While most schemes offer you an OTC (over-the-counter) benefit where you can buy certain acute medicines without a prescription, unnecessary purchases will quickly exhaust your benefit. Speak to your pharmacist about cash rates for medicines and any additional administration or prescription fees.
  • Do not visit health care practitioners unless you need medical attention. Consulting with a physiotherapist or chiropractor for the odd massage may be unnecessary and could deplete your funds quickly.
  • Prevention is better than cure. Keep yourself healthy by eating a balanced diet and exercising and this will may reduce your visits to the doctor.
  • Generic drugs may be a cheaper option and your pharmacist will be able to advise you accordingly.
  • Do not collaborate with any practitioner or pharmacy to provide non-medical services on your medical aid. This is a crime and it will affect your medical benefits in the long run.
  • Speak to your medical aid about HIV/AIDS management programs which will allow you to access to quality health care services without depleting your medical aid funds prematurely.
  • Informing your medical aid about your chronic ailment will allow you to access chronic cover benefits which will not exhaust your out-of-hospital benefit.