Currently, your medical scheme has to offer cover for certain chronic conditions, in addition to certain existing benefits.
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?
* 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:
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.