The ins and outs of med­i­cal aid cover

It is cru­cial to un­der­stand your scheme’s pre­scribed min­i­mum ben­e­fits to avoid any sur­prises in terms of co­pay­ments, writes Maya Fisher-French

CityPress - - Tenders -

To pro­vide lower-cost med­i­cal cover, most med­i­cal schemes of­fer plan op­tions where co­pay­ments ap­ply for cer­tain pro­ce­dures. These pro­ce­dures tend to be elec­tive surg­eries such as a colonoscopy or joint re­place­ment and are clearly de­fined in the med­i­cal schemes brochure.

There is, how­ever, some con­fu­sion sur­round­ing when co­pay­ments may ap­ply for pre­scribed min­i­mum ben­e­fits (PMBs). A court rul­ing in 2011 found that med­i­cal schemes must pay for PMBs in full and co­pay­ments may not ap­ply. PMBs stip­u­late the min­i­mum level of di­ag­no­sis, treat­ment and care that med­i­cal schemes must pay for in full from the risk por­tion, and not from mem­ber sav­ings. These cover chronic con­di­tions such as can­cer and di­a­betes, as well as any emer­gency con­di­tions.

This, how­ever, is not a blan­ket rul­ing and, as a mem­ber, you need to un­der­stand that if you do not follow the scheme rules, co­pay­ments could still ap­ply.

Ac­cord­ing to Dr Elsabé Con­radie of the Coun­cil for Med­i­cal Schemes, if a mem­ber choses to use the ser­vices of a non-des­ig­nated ser­vice provider, a co­pay­ment can be charged by a med­i­cal scheme.

A des­ig­nated ser­vice provider is a doc­tor, spe­cial­ist, hospi­tal or any med­i­cal ser­vice provider that has been con­tracted to the med­i­cal scheme. If you, as a mem­ber, de­cide not to use the ser­vice provider elected by your scheme, even if it is for a treat­ment that falls un­der the pre­scribed min­i­mum ben­e­fits, the scheme is en­ti­tled to charge a co­pay­ment.

If, how­ever, you in­vol­un­tar­ily have to use the ser­vices of a non-des­ig­nated ser­vice provider, such as in the case of an emer­gency, the scheme will pay the bill in full.

Con­radie pro­vides the fol­low­ing case that came be­fore the Coun­cil for Med­i­cal Schemes to il­lus­trate when a co­pay­ment be­comes due:

Jan­uary 1 – A mem­ber who is on hol­i­day in the West­ern Cape is hik­ing on a moun­tain, slips, falls and breaks a shoul­der. She is rushed to the near­est hospi­tal and is ad­mit­ted as an emer­gency and is di­ag­nosed with a PMB con­di­tion – closed frac­ture/dis­lo­ca­tion of limb bones, code 902H, the treat­ment of which is spec­i­fied in the Med­i­cal Schemes Act as re­duc­tion or re­lo­ca­tion of the limb.

Jan­uary 2 – The mem­ber spends a night in hospi­tal and de­cides to fly back to Jo­han­nes­burg.

Jan­uary 3 – She con­sults with a non-des­ig­nated ser­vice provider or­thopaedic sur­geon, who ad­vises her that she needs a to­tal shoul­der re­place­ment. Autho­ri­sa­tion was granted by her med­i­cal scheme for the pro­ce­dure as well as the level of the re­im­burse­ment of her claims should she use the ser­vices of a non­des­ig­nated ser­vice provider.

Jan­uary 4 – The re­con­struc­tion of the mem­ber’s shoul­der was per­formed at a non-des­ig­nated ser­vice provider hospi­tal and the mem­ber stayed in hospi­tal for four days.

The med­i­cal scheme paid for all med­i­cal bills in full as it re­garded the ad­mis­sion at the first hospi­tal as an emer­gency PMB ad­mis­sion. How­ever, it short-paid some of her claims re­lated to the sec­ond hos­pi­tal­i­sa­tion episode as the mem­ber used the ser­vices of a non­des­ig­nated ser­vice provider. The med­i­cal scheme also im­posed a limit on the pros­the­sis used as per its rules, as well as a co­pay­ment for joint re­place­ment.

The mem­ber dis­putes the co­pay­ment im­posed, as well as the short-pay­ment of some of her claims. In ar­riv­ing at its de­ci­sion, the coun­cil’s ap­peals com­mit­tee found that:

1) Shoul­der re­place­ment is not a PMB level of care. The PMB level of care in re­spect of the mem­ber’s in­juries is specif­i­cally stip­u­lated in an­nex­ure A of the reg­u­la­tions of the Med­i­cal Schemes Act as “re­duc­tion and re­lo­ca­tion, not re­place­ment”.

2) The pro­ce­dure per­formed in Jo­han­nes­burg did not con­sti­tute an emer­gency as con­tem­plated in the reg­u­la­tions of the act and there was noth­ing pre­vent­ing the pa­tient from re­ceiv­ing ser­vices from des­ig­nated ser­vice providers of her med­i­cal scheme.

3) The ap­peals com­mit­tee held that the pa­tient’s med­i­cal scheme acted in ac­cor­dance with its rules when im­pos­ing a co­pay­ment for joint re­place­ment and that the short­fall on the amount charged for the pros­the­sis was jus­ti­fied.

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