Here’s how to stretch your cover.
It happens to almost every medical aid member at some point: winter has come and gone, the last of the season’s coughs and colds are clearing up, and your day-to-day or savings benefit is already looking stretched. Every sniffle, ache or routine check-up suddenly feels like a financial burden. For many South African families, this time of the year brings a familiar squeeze on the household budget, with several more months still to go before annual limits reset.
The good news is that running out of cover doesn’t have to mean compromising on care or paying full price out of pocket. A mix of smarter use of benefits, virtual healthcare and pharmacy-based services can help you manage everyday health needs even once your savings or day-to-day funds are depleted. Here’s what to know.
Where the money actually goes
The day-to-day or savings portions of a medical aid plan are designed to cover routine expenses, such as GP visits, over-the-counter medications, basic tests and check-ups. However without proper planning, you can burn through the allocated benefits well before December.
You may have more cover than you think
Many people assume that once day-to-day or savings funds are depleted, they have no cover left at all, but that’s rarely the case. Chronic medication, for example, is generally covered by a separate Chronic Medicine Benefit rather than day-to-day or savings funds, provided the condition and medicine are registered with your scheme. Hospital cover, PMBs (Prescribed Minimum Benefits) and certain risk-funded benefits also continue regardless of your available day-to-day or savings balance.
Some schemes fund a portion of routine care from risk contributions rather than day-to-day savings. Medshield members have access to virtual GP and specialist consultations funded from risk (depending on your chosen benefit plan), in addition to the standard in-person GP benefit. Other benefits include an annual wellness benefit and an eye test covered from risk, for instance. It’s worth asking your scheme or consulting you benefit guide to determine what, specifically, falls into that category on your plan. It varies significantly scheme to scheme and plan to plan.
Prioritise your care early next year
One habit that makes a real difference is timing. Planning non-urgent check-ups, medication refills, and dental or optical visits early in the year, and if you have a chronic condition, registering now may still be beneficial. This way, ongoing costs will be covered under the Chronic Medicine Benefit, rather than depleting your savings or day-to-day funds for the remainder of the year.
Ask about Virtual Consultations
Telehealth has grown significantly in South African healthcare since the COVID-19 pandemic, and some schemes and independent providers now offer video or phone consultations with a doctor, nurse, or mental health professional as an alternative to an in-person GP visit. These are usually more affordable than an in-person GP visit and are well suited for prescription renewals, minor ailments, mental health support, and follow-up advice on chronic conditions. Many members may not realise that their medical scheme funds these consultations separately rather than using their savings, so check your benefits and what they offer.
Try a pharmacy clinic before booking a GP
Over the past few years, one of the most notable changes in local healthcare has been the growth of nurse-led clinics within major pharmacy chains. These clinics provide services such as blood pressure checks, vaccinations, minor ailment treatments and chronic disease monitoring at a fraction of the cost of a private GP consultation. Some schemes also have specific network agreements with these clinics that include a built-in telemedicine option. If a nurse assesses that a virtual doctor consultation is necessary, they can facilitate that on-site, allowing the patient to receive a prescription that can be filled immediately at the same pharmacy. For members whose day-to-day or savings have been exhausted, this option often becomes one of the most cost-effective ways to address minor health issues quickly.
Ask your pharmacist about generics
Generic medicines cost a fraction of branded equivalents and are held to the same efficacy and safety standards by South Africa’s medicines regulator. Under Section 22F of the Medicines and Related Substances Act, pharmacists are required to offer a generic substitute unless the prescribing doctor has specifically indicated otherwise or the patient declines.
Making it through to December
Rising healthcare costs and mid-year benefit crunches aren’t going away, but the tools available to manage them have improved. Reviewing what’s still covered, using virtual and pharmacy-based care where appropriate, and opting for generics where possible can all help you stretch benefits further without compromising access to healthcare when you need it most.
Make sure to read your scheme’s benefit guide carefully rather than browsing through it. Medshield members can access the SmartCare Benefit, which includes in-pharmacy/clinic consultations led by Nurse Practitioners at over 600 Clicks and Dis-Chem stores, as well as other network clinics. These Nurse Practitioners can connect patients to a doctor virtually and fill prescriptions on-site, often at a fraction of the cost of an in-person GP visit. A few minutes spent reviewing your plan’s benefit guide could provide piece of mind throughout the year.
ENDS
