Health issues affecting women
It is important to educate yourself as a woman about health conditions that may affect you.
Here’s a selection of health issues affecting women and how PMBs protect and ensure women get the care they need.
INFERTILITY
Infertility is a global health issue affecting millions of people of reproductive age worldwide.
It is the inability to become pregnant after one year of unprotected sex and after six months in women over age 35. It may present as too long a cycle (35 days or more) or too short a cycle (21 days), an irregular or absent cycle that means one may not ovulate.
Infertility testing and treatment are extremely expensive, and for most couples, the main question and concern is whether they can afford it. Therefore, it is important to determine how infertility is covered by the prescribed minimum benefits. The PMB regulation includes infertility but states that medical and surgical management shall be limited to nine procedures and interventions.
OVARIAN CYSTS
Ovarian cysts are often discovered incidentally during a routine pelvic examination or abdominal ultrasound. However, ovarian cysts cause symptoms if they rupture, are very large or block the blood supply to the ovaries.
Ovarian cysts can sometimes make it harder to conceive. If surgery is needed to remove cysts, the doctor will perform the procedure while aiming to preserve fertility as much as possible. This may mean removing a cyst and leaving the ovaries intact or only removing one ovary. When both ovaries need to be removed, the body will no longer be able to produce any eggs. It is important to understand the effects of surgery on fertility before the procedure is done.
“Ovarian cysts” are included in PMB regulations under Diagnosis and Treatment Pair (DTP) code 434M. This DTP refers to “Non-inflammatory disorders and benign neoplasms of the ovary, fallopian tubes and uterus”. The Treatment component specified for this DTP is “Salpingectomy; oophorectomy; hysterectomy; medical and surgical management”.
The medical schemes must pay for the full diagnosis, treatment, and follow-up consultations and treatment if the services were obtained from a designated service provider (DSP). In case of an emergency, healthcare services must be paid in full, even if a non-DSP was used. Read more on Ovarian Cysts here.
TERMINATION OF PREGNANCY
Termination of pregnancy or abortion is when a woman chooses to end a pregnancy for various reasons.
Abortion in South Africa is legal on request. The Choice on Termination of Pregnancy Act No. 92 of 1996 gives all women the right to have a safe abortion, on request, with no conditions during the first 12 weeks of pregnancy. The procedure can be performed by a medical doctor, nurse, or registered midwife.
The Act also allows for the abortion to be performed between 13 to 20 weeks of pregnancy by a doctor if, after consultation with the pregnant woman, the healthcare practitioner believes that:
- Pregnancy poses a risk to the woman’s physical or mental health.
- The risk of severe physical or mental abnormality in the unborn baby is substantial.
- Pregnancy resulted from rape or incest.
- The continued pregnancy would significantly affect the social or economic circumstances of the pregnant woman.
After 20 weeks of pregnancy, abortion can be performed by a medical doctor if the pregnancy endangers the woman’s life or the unborn baby’s health.
“Voluntary termination of pregnancy” is a PMB condition under Diagnosis and Treatment Pair (DTP) code 296M. The treatment component specified for this DTP is “Induced abortion; medical and surgical management”. The medical schemes must pay for the consultations, tests, medicines, medical or surgical abortion, and follow-up consultations and treatment in full if the services were obtained from a designated service provider (DSP).
CERVICAL CANCER
Worldwide, cervical cancer is the fourth most common cancer in women. In South Africa, cervical cancer has been identified as a national priority, as 1 in every 42 women has a lifetime risk of being diagnosed with cervical cancer. However, it can be treated successfully if detected in early.
Diagnosis and Treatment Pair (DTP) code 960M. Treatable cervical cancer is a PMB condition under DTP code 954M – Cancer of Cervix – treatable. According to the PMB regulation, treatable cancers are defined as follows:
- they involve only the organ of origin and have not spread to adjacent organs;
- there is no evidence of distant metastatic spread;
- they have not, by means of compression, infarction, or other means, brought about irreversible and irreparable damage to the organ within which they originated (for example, brain stem compression caused by a cerebral tumour) or another vital organ;
- if points (i) to (iii) do not apply, there is a well-demonstrated five-year survival rate of greater than 10% for the given therapy for the condition concerned.
According to the PMB regulations, schemes must pay for the diagnosis, treatment and care costs of treatable cervical cancer, irrespective of the medical scheme option a member belongs to. This would include consultations with doctors and other health professionals, surgery, radiology, pathology, chemotherapy and radiation therapy. If cancer has spread, the only treatment that does not provide a five-year survival benefit of more than 10% is not PMB level of care. In such instances, clinically appropriate healthcare services must be funded.
BREAST CANCER
Breast cancer is a disease in which the cells of the breast do not grow normally; they grow out of control.
Treatable breast cancer is included in the Prescribed Minimum Benefits (PMB) regulations under DTP 950J. Treatable cancers are defined in the PMB regulations as solid organ malignant tumours where:
(i) they involve only the organ of origin, and have not spread to adjacent organs
(ii) there is no evidence of distant metastatic spread
(iii) they have not, by means of compression, infarction, or other means, brought about irreversible and irreparable damage to the organ within which they originated (for example brain stem compression caused by a cerebral tumour) or another vital organ
(iv) or, if points (i) to (iii) do not apply, there is a well-demonstrated five-year survival rate of greater than 10% for the given therapy for the condition concerned.
Regardless of which benefit option a member or beneficiary is on, the medical scheme must pay for the diagnosis, treatment, and care costs of treatable breast cancer. Screening through a physical breast examination, consultations with doctors and other health professionals, surgery, radiology, pathology, chemotherapy, and radiation therapy and breast reconstruction are included in what the medical scheme must cover.
OVARIAN CANCER
Treatable ovarian cancer is a Prescribed Minimum Benefit (PMB) condition under Diagnosis and Treatment Pair (DTP) code 952M – Cancer of ovary – treatable. According to the PMB regulation, treatable cancers are defined as follows:
- they involve only the organ of origin and have not spread to adjacent organs;
- there is no evidence of distant metastatic spread;
- they have not, by means of compression, infarction, or other means, brought about irreversible and irreparable damage to the organ within which they originated (for example, brain stem compression caused by a cerebral tumour) or another vital organ;
- if points (i) to (iii) do not apply, there is a well-demonstrated five-year survival rate of greater than 10% for the given therapy for the condition concerned.
According to the PMB regulations, schemes must pay for the diagnosis, treatment and care costs of treatable ovarian cancer, irrespective of the medical scheme option a member belongs to. This would include consultations with doctors and other health professionals, surgery, radiology, pathology, chemotherapy and radiation therapy.
Council for Medical Schemes has published the PMB Definition Guidelines for ovarian cancer. These provide detailed information on the treatment options that are PMB level of care and those that are not.
