Things you must do to get your chronic condition covered
Natasha suffers from Crohn's disease, which she's been battling to manage. Last month, she spent eight days in hospital for malnutrition and while her hospital stay was covered by her scheme Fedhealth, part of her doctor's bill and her medicines amounting to R6,500 were not.
The deterioration of her condition and admission to hospital, as well as the unrecouped costs, are the result of her not receiving or following the treatment protocol developed by her scheme.
Fedhealth principal officer Jeremy Yatt says Natasha's case highlights the apathy of members who fail to understand their medical scheme, and especially disease management programmes.
"There's this perception that the scheme is trying to make you jump through hoops [to obtain benefits]. We want the member to get the most effective treatment at the best price."
Yatt says it often happens that members with chronic conditions don't register their conditions with the scheme, use designated service providers (DSPs) to avoid co-payments and follow treatment protocols.
"People, generally, don't engage until they are confronted with a claim that isn't paid in full," he says.
If you're a member of a medical scheme and have a chronic condition that is one of the 25 common chronic illnesses that schemes must cover, you need to know how to access these benefits.
The benefits covering these chronic conditions are known as prescribed minimum benefits (PMBs) and in terms of the Medical Schemes Act all medical schemes must cover the costs related to the diagnosis, treatment and care of these conditions.
Irrespective of your benefit option, your scheme must provide cover for PMBs, Bianca Viljoen, spokesperson for Health Squared Medical Scheme, says.
But cover isn't automatic. Here's what you need to do:
Apply to register your condition
Discovery Health, the country's largest open scheme, requires that you or your doctor submit a chronic illness benefit application to the scheme. In addition, you may need to send the scheme the results of tests confirming the diagnosis of your condition.
The Council for Medical Schemes (CMS) says schemes can make a benefit conditional on the member 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," the CMS website says.
In Natasha's case, her scheme provided for a visit to a specialist that would most likely have helped her get on the right medication and avoid being hospitalised.
Members with chronic conditions must find out what their scheme's requirements are for them to access benefits, Viljoen says.
David Green, the MD of Med ClaimAssist, says doctors are sometimes lax in classifying a condition as a PMB. Just because your doctor says you have a PMB doesn't mean your scheme will agree.
Designated service providers
These are doctors, specialists, pharmacists or other health-care providers with whom your scheme has a payment arrangement. If you choose not to use one or more of these designated service providers (DSPs) to treat your chronic condition, you may be in for a co-payment.
Discovery recently notified members that from next month members on Priority and Saver plans with a chronic condition that was approved before 2019 need to use a MedXpress Network Pharmacy for their drugs to avoid a 20% co-payment.
The CMS says that if your scheme expects you to use a DSP, it must inform you. The scheme must list its DSPs and say what it will or won't pay if you fail to use a DSP.
Follow treatment protocol
Your scheme can insist that it will only fund treatment that follows an appropriate protocol. These treatment protocols must provide a standard of care that is not lower than the care you would get in most public health-care facilities.
Treatment protocols for each of the chronic conditions which have been made PMBs have been published in the Government Gazette. And the Chronic Diseases List has algorithms specifying medicines and other treatment interventions, which have also been published in the gazette.
"Your medical scheme may develop protocols to manage the use of benefits," the CMS says. "Such protocols would specify, for example, types of tests, investigations and number of consultations. Members who might need more frequent or extra services . can appeal to their scheme for these to be covered."
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 protocols.
If you and your doctor decide that you should rather use different medication to that in the treatment protocol, then you may have to pay a co-payment.