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Currently,
your medical scheme has to offer cover for certain chronic conditions, in
addition to certain existing benefits
Click on any of the Questions below to navigate
to a specific section:
Is my medical scheme obliged by law to
provide cover for certain medical conditions?
Yes, these are known as Prescribed Minimum Benefits (PMBs). They were
introduced into the Medical Schemes Act to ensure that members of medical
schemes would not run out of benefits for certain conditions and find
themselves forced to go to state hospitals for treatment. These PMBs cover a
wide range of close to 300 conditions, such as meningitis, various cancers,
menopausal management, cardiac treatment and many others including medical
emergencies.
Many years ago, medical schemes provided minimum benefits but these were
gradually whittled away until the Medical Schemes Act of 1998 was promulgated
offering greater protection for consumers.
These benefits are provided for largely in hospitals, and where your medical
scheme has made arrangements for you to be treated. Most schemes pay for
treatment in private hospitals, but they should make arrangements with
hospitals or hospital groups in which their members are to be treated. These
arrangements, including those made with state hospitals, should be reflected in
the rules of the scheme.
Always check your benefits with your scheme and make sure you have the scheme's
rules at your disposal.
Is it true that schemes now also have to
provide chronic medication?
Yes, the list of prescribed minimum benefits (PMBs) has been extended to cover
25 common chronic diseases from January 1 next year.
Medical schemes have to provide benefits that cover you for the diagnosis,
treatment and care of these 25 chronic illnesses. However, you should remember
that a scheme does not have to pay for diagnostic tests that establish that you
are suffering from a disorder that is NOT one of the 25 chronic ailments.
The inclusion of the 25 chronic conditions in the list of PMBs is a major step
towards helping people who have struggled to pay for their treatment of chronic
diseases, and have increasingly had to dip into their own pockets for this
treatment.
In order to contain the costs of providing such cover to you, certain measures
have been put in place to ensure that schemes can cover those members who need
it, without putting the scheme at financial risk.
So schemes are entitled to expect you to obtain treatment for a PMB from
certain providers, the so-called "designated service providers" - particular
groups of hospitals, clinics, doctors, retail pharmacies, and so on. However, a
scheme must state in its rules that you must use a designated service provider
and you must be informed about where and how you can get medication and
treatment from that provider.
Schemes that do not include these arrangements in their rules and do not inform
members, risk having to pay for the cost of treatment from whichever provider
you use.
If you do not abide by the rules about which providers to use, you face having
to pay all or part of the cost of your treatment yourself.
The "treatment protocols" (guidelines for appropriate treatment) for each of
the chronic conditions, which have been made PMBs, have been published in the
Government Gazette.
This is so that you may be assured of good quality treatment and your scheme
can be sure that it will not have to pay for unnecessary treatment. Your doctor
should know and understand the guidelines so that he or she can help you get
the treatment you need for any of these conditions without incurring costs that
your scheme does not cover.
Why have 25 chronic illnesses been made
PMBs?
By making these benefits mandatory, the government, on the Council for Medical
Scheme's recommendation, hopes to stamp out attempts by schemes to rate members
on the financial risk they pose to a scheme because of the state of their
health. The Medical Schemes Act introduced the principle of community rating,
whereby members of a scheme (or one of its options) pay the same rates for
cover, regardless of their state of health. However, medical schemes have been
making chronic benefits available only on options with higher contribution
levels. In this way people with chronic conditions were effectively being
risk-rated and forced to pay higher amounts for their cover.
Which 25 illnesses are covered?
Addison's disease
Asthma
Bipolar mood disorder*
Bronchiectasis
Cardiac failure
Cardiomyopathy
Chronic obstructive pulmonary disorder
Chronic renal disease
Coronary artery disease
Crohn's disease
Diabetes insipidus
Diabetes mellitus types 1 & 2
Dysrhythmias
Epilepsy
Glaucoma
Haemophilia
Hyperlipidaemia
Hypertension
Hypothyroidism
Multiple sclerosis
Parkinson's disease
Rheumatoid arthritis
Schizophrenia
Systemic lupus erythematosus
Ulcerative colitis
* Will only be covered when an algorithm has been developed.
Why are some chronic illnesses covered and some not?
The diseases that have been chosen are the most common,
are life threatening, and those for which treatment would improve the quality
of the member's life.
What is a designated service provider?
Your medical scheme may choose a healthcare provider or group of providers
(doctors, pharmacists, hospitals, network, or so on) to be the preferred
provider or providers to its members when they need diagnosis, treatment or
care for a prescribed minimum benefit (PMB) condition.
If you do not use the designated service provider your scheme has chosen, you
may have to pay the costs yourself, or your scheme may only pay as much as it
would have cost you to make use of the designated service provider, and you
will have to pay the difference.
If your scheme expects you to use a designated service provider, it must inform
you and the rules of the scheme must also state which service providers are the
designated ones and what the scheme will or won't pay if you use a provider
other than the designated one.
The Council for Medical Schemes believes that if your scheme does not appoint a
designated service provider, you are entitled to obtain a service listed in the
PMBs from any provider and the scheme must pay.
When can I use a doctor, pharmacist or hospital other than a designated
service provider?
The regulations provide for instances in which it is not possible for you to
make use of the designated service provider for the diagnosis, treatment or
care of a prescribed minimum benefit (PMB) condition. For example, if you need
treatment very urgently. In this case you will be regarded as having obtained
the service involuntarily and the scheme will have to pay. The three cases in
which you will be regarded as having obtained the service involuntarily are:
i) If the service was not available from the designated service provider or
could not be provided without an unreasonable delay;
ii) If you needed immediate treatment under circumstances that prevented you
from using the designated service provider; and
iii) If there was no designated service provider within reasonable proximity of
your place of work or residence.
Does my scheme need to do anything to ensure that the designated service
provider can treat me?
The Council for Medical Schemes has been advising schemes to enter into
contracts with any designated service provider they choose, especially state
hospitals, to ensure that these providers can supply the necessary services.
Many state hospitals have set up separate wards, designed to serve members
whose treatment and hospital stay is paid for by their medical scheme and to
whom the hospital can afford to provide better service. Other schemes have made
arrangements with private hospital and certain retail pharmacies to treat their
members.
Yes, medical schemes can make a benefit conditional on you obtaining
pre-authorisation or joining a chronic medication benefit management programme.
These programmes are aimed at educating members about the nature of their
disease and equipping them to manage it in a way that keeps them as healthy as
possible. For example, many schemes offer treatment through groups that manage
diseases such as diabetes, and are equipped to give the medication and monitor
that disease.
Can my scheme insist that it will only fund treatment that follows the
appropriate protocol?
Yes. The minimum standards of treatment for all prescribed minimum benefit
conditions have been published in the Government Gazette, and are known as
treatment algorithms (benchmarks for treatment). Your scheme may decide what
treatment it will pay for for each chronic condition, but the treatment may not
be below the standards published in the treatment protocols.
If your scheme's cover conforms to that standard and you and your doctor decide
that you should follow a different treatment regimen, then you may have to pay
towards the cost of that treatment.
Can my scheme refuse to cover my medication if I need, or want, a brand
other than that which the scheme says it will pay for?
It may refuse to cover all the expenses. Your scheme may draw up what is known
as a formulary - a list of safe and effective medicines that can be prescribed
to treat certain conditions.
The scheme may state in its rules that it will only cover you if your doctor
prescribes a drug on that formulary. Often the medicines on the list will be
generics - cheaper copies of the original brand name drug. If you want to use a
brand name medicine which is not on the list, your scheme may refuse to pay for
that medicine, or it may foot only part of the bill and you will have to pay
the difference between the price of the medication you use and the one on the
formulary.
If you suffer from specific side effects from drugs on the formulary, or if a
substituting drug on the formulary with one you are currently taking affects
your health detrimentally, you will be able to put your case to your medical
scheme and ask the scheme to pay for your medicine.
Generally, however, it is likely that the scheme will expect you to stick to
the medication on the formulary.
Can my scheme make me pay for a PMB from my savings account?
No, the regulations state that schemes cannot use your medical savings account
to pay for prescribed minimum benefits (PMBs). Some schemes, especially those
that have appointed state hospitals as their designated service provider, are
suggesting that members who do not want to use the designated service provider,
or members who want to take medication not included on the scheme's formulary,
can use their savings accounts to pay for this medication. The Council for
Medical Schemes regards this as a contravention of the law.
Can my scheme make me pay a co-payment or levy on a PMB?
No, your scheme cannot charge you a co-payment or levy on a prescribed minimum
benefit (PMB). However, if your scheme appoints a designated service provider
and you voluntarily use a provider other than a designated one, your scheme may
charge you the difference between the actual cost and what it would have paid
if you had used the designated service provider.
Do the PMBs only cover the chronic medication I need to take?
No, if you have one of the 25 listed chronic diseases, your scheme must pay for
any diagnosis, treatment and care related to that condition. This means that
your scheme must also pay for your consultations and tests related to your
condition. Your scheme need not pay for the diagnostic tests if the disease
proves not to be a prescribed minimum benefit (PMB) condition.
Will benefits for chronic illnesses other than the listed 25 be
reduced?
Many schemes do extend chronic medicine benefits beyond these 25 conditions,
but this will vary between benefit options and between schemes. Ultimately the
trustees of your medical scheme have the right to decide which benefits to
provide for the level of contributions made by members.
Can schemes still set a chronic medicine limit?
Yes, your scheme can set a limit for chronic medicine benefit and any chronic
medication you claim for will then reduce that limit, regardless of whether or
not it is one of the 25 prescribed minimum benefit (PMB) chronic conditions.
However, if your scheme has a chronic medicine limit and you exhaust it, your
scheme will have to continue paying for any chronic medication you obtain from
its designated service provider for a PMB condition.
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