Countless clauses and fine print muddy the waters
Good medical scheme benefits are essential if you're ever faced with the high costs of cancer treatments.
Good news is that, as long as you are on medical aid, you can upgrade to an option with better benefits at the end of each year.
Healthcare advisers say you can tell whether your scheme offers good benefits by checking the following:
• The overall limit on oncology;
• The limits on specialised medicines;
• The treatment protocols; and
• Cover for reconstructive surgery.
The overall limit
Most medical scheme options limit oncology benefits to an annual rand amount.
For example, the country's largest medical aid, Discovery Health Medical Scheme, pays a maximum of R200,000 a year per person on its cheaper Priority, Saver, Smart and Core plans, and double that for its more expensive Executive and Comprehensive plans. However, these limits have not been increased in seven years, says oncologist Dr Waldemar Szpak.
Once you have exhausted these limits, benefits on all of Discovery's plans are unlimited, but you have a 20% co-payment, which could end up being expensive.
The largest restricted scheme for government employees, the Government Employees Medical Scheme, has different limits on its options, ranging from R197,567 per family on the cheaper Beryl option, to R439,330 annually on the top Onyx option.
Jill Larkan, the head of healthcare consulting at GTC Healthcare, says there are a few options that offer unlimited oncology benefits.
Some schemes offering unlimited benefits make them available through a network of scheme-approved oncologists - but treatment options are limited to the scheme's protocols and can exclude unproved drugs.
So what are these protocols? Most schemes offer benefits for cancer based on one of three tiers developed by the South African Oncology Consortium, the body which accredits South African oncologists.
The consortium's basic level of benefits is equivalent to the prescribed minimum benefits that all schemes are legally obliged to give medical aid members.
The consortium's third-tier - or "motivation" - benefits are offered on the most expensive plans, and allow you access to specialised drugs if doctors motivate for them.
Anthea Towert, manager of health benefits at Axiomatic Consultants, says the benefit tiers can be more important that the overall limit: a more expensive comprehensive plan is likely to have richer benefits than a hospital plan even if they have the same limit.
Schemes typically have treatment protocols and medicine lists, but if your oncologist deviates from them, you may not be covered.
But it's not easy to get these protocols, despite regulations under the Medical Schemes Act obliging medical aids to give you information. The schemes claim the protocols are their intellectual property.
This lack of information has been raised by consumer rights groups, says Towert.
So hire a healthcare broker - they are able to get the protocols more easily than members, Towert says. Their services are essentially free, as they earn commission from medical schemes and your contributions remain the same regardless.
Your broker will do a financial needs analysis to help you choose your medical aid option. Find one on medicalschemes.com and check their licences on fsb.co.za
Cover for specialised medicines
Newer specialised medicines for cancer are often expensive and your scheme may exclude them.
Some medical aids have sub-limits for these medicines in the oncology limit. For example, on the most comprehensive option for government employees, you can only spend R296,944 per family for specialised medicines.
Towert says it is difficult to work out cover for the specialised medicines, because each scheme decides whether to pay depending on which tier of treatment the medicine is on.
Cover for reconstructive surgery
Your scheme's oncology and major medical benefits may or may not include reconstructive surgery, after, for example, a mastectomy. Check the fine print, Larkan says. Only two schemes, Genesis and Medshield, offer seperate benefits for this surgery.