|Medical scheme beneficiaries
|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 beneficiaries 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 ±270 conditions, such
as meningitis, various cancers, menopausal management, cardiac
treatment and many others, including medical emergencies. However,
take note that certain limitations could apply, such
as the use of a Designated
Service Provider and specified treatment standards.
PMB diagnosis, treatment and care are not limited to hospitals.
Treatment can be received wherever it is most appropriate, including
a clinic, outpatient setting or even at home. Always check your benefits with your medical 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 PMBs includes 25 common chronic diseases
in the Chronic Disease List (CDL) and other chronic conditions
within the ±270 Diagnosis Treatment
Pair (DTP) section.
Medical schemes have to provide cover for the diagnosis, treatment
and care of these diseases. However, you should remember that
a medical scheme does not have to pay for diagnostic tests that
establish that you are not suffering from a PMB condition.
The treatment algorithms (guidelines for appropriate treatment)
for each of the CDL chronic conditions have been published in
the Government Gazette while the chronic diseases in the DTP
section are guided by the public sector protocols. This assures
you of good quality treatment and reassures your medical scheme
that it will not have to pay for unnecessary treatment. Your
doctor should know and understand most of 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
| Why are some chronic illnesses covered and some not?
| The diseases that have been chosen are the most common, they
are life-threatening, and are those for which cost-effective
treatment would sustain and improve the quality of the member's
| 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 medical
schemes to enter into contracts with any DSP they choose, especially
State hospitals, to ensure that these providers can supply the
necessary services. Many State hospitals have set up separate
wards to serve beneficiaries whose treatment and hospital stay
is paid for by their medical scheme and to whom the hospital
can then afford to provide better service. Other schemes have
made arrangements with private hospital and certain retail pharmacies
to treat their beneficiaries.
| Can I be refused cover for the chronic
conditions if I do not get authorisation or have certain tests?
| Yes, medical schemes can make a benefit conditional
on you obtaining pre-authorisation or joining a 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
Can my scheme insist that it will only fund treatment
that follows the appropriate protocol?
| Yes. The minimum medicines for treatment
of all PMB conditions have been published in the Government Gazette,
and are known as treatment algorithms (benchmarks for treatment).
Your scheme may decide for which medicines it will pay 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 rather use different medication, then you may have
to pay a co-payment towards the cost of that medicine. Your medical
scheme must, however, pay for the treatment if your doctor can
prove that the standard medication is ineffective or detrimental
to your condition.
Your medical scheme may develop protocols to manage the use of benefits. Such
protocols would specify, for example, types of tests, investigations and number
of consultations. Members who might need more frequent or extra services than
provided for in the protocols, can appeal to their scheme for these to be covered.
The scheme’s appeal process might include a motivation from the treating
doctor that explains the clinical reasons for the additional services
| 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?
| Yes, the medical scheme may refuse to cover
a part of 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 your medication in full if
your doctor prescribes a drug on that formulary. Generally speaking,
schemes expect their members to stick to the formulary medication.
Often the medicines on the list will be generics – copies
of the original brandname drug – that are less expensive
but equally effective. If you want to use a brandname medicine
that is not on the list, your medical scheme may foot only part
of the bill and you will have to pay either the difference between
the price of the medication you use and the one on the formulary,
or a percentage co-payment as registered in the scheme rules.
If you suffer from specific side-effects from drugs on the
formulary, or if substituting a drug on the formulary with one
you are currently taking affects your health detrimentally, you
can put your case to your medical scheme and ask the scheme to
pay for your medicine. You can also appeal to the scheme if the
formulary drug is ineffective and does not have the desired effect.
If your treating doctor can provide the necessary proof and the
scheme agrees that you suffer from side-effects, or that the
drug is ineffective, then the scheme must give you an alternative
and pay for it in full.
| 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 PMBs.
| 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 PMB if you follow the scheme formulary and protocol.
However, if your scheme appoints a Designated
Service Provider (DSP) and you voluntarily use a different provider, your scheme
may charge you the difference between the actual cost and what
it would have paid if you had used the DSP or the percentage
co-payment as registered in the scheme rules.
| Can schemes still set a chronic medicine
| Yes, your scheme can set a limit for your
chronic medicine benefit. Any chronic medication you claim for
will then reduce that limit, regardless of whether or not it
is one of the PMB chronic conditions. However, if you exhaust
your chronic medicine limit, your scheme will have to continue
paying for any chronic medication you obtain from its DSP for
a PMB condition.