Health scheme queries
The two national health insurance schemes, MySalam and PeKa, require more clarity on how they are to work.
TWO national health insurance schemes – Skim Perlindungan Nasional B40 (MySalam) and Skim Perlindungan Kesihatan (PeKa) – were launched last month.
Their objectives are to provide insurance for the B40 (bottom 40%) household income group in the event they develop 36 critical illnesses in the former, and the screening of a projected 800,000 of B40 Malaysians aged 50 years and above for non-communicable diseases (NCDs) in the latter.
Eligible persons treated at Health Ministry hospitals can make claims from MySalam from Mac 1.
Likewise, the screening for NCDs under PeKa will begin from the same date.
What’s included in MySalam?
MySalam provides a one-off contribution of RM8,000 directly to those suffering from any of the critical illnesses covered under the scheme, including heart disease, cancer and Alzheimer’s disease.
Those eligible will also get RM50 daily for 14 days should they be admitted to Health Ministry hospitals. This is limited to a maximum of RM700 per year.
The MySalam scheme is funded by a RM2bil contribution from insurance company Great Eastern Malaysia, with Great Eastern Takaful being the insurer.
This contribution is used to pay the premium for the scheme, which was estimated at RM112 per person annually, for five years.
Healthcare professional associations have stated that they were not consulted on MySalam.
Some essential aspects of MySalam are unknown. Important issues include the definitions of critical illness and exclusions from the scheme.
Are the definitions of critical illness in MySalam the same as that as listed in Great Eastern Malaysia’s website?
Are there any exclusions from MySalam, and if so, are they the same as that listed in Great Eastern Malaysia’s website?
In the company’s brochure titled Great Early Living Care - Supports you right from the start of a critical illness, the exclusions statement is:
“A: No benefit is payable under the following circumstances:
• Pre-existing illness.
• Death during the first policy year as a result of suicide, while sane or insane.
• TPD (total and permanent disability) resulting from self-inflicted injuries, while sane or insane.
• Critical illnesses which commence, occur or are diagnosed during the waiting period of 30 days or 60 days (depending on the stage and type of critical illness) from the policy issue/reinstatement date, whichever is later.
“In addition, Special Benefit is not payable under the following circumstances:
• The Life Assured (the person covered by the insurance policy) did not survive for at least seven days after the diagnosis of an Early Stage Cancer or Early Stage End Stage Liver Failure, as the case may be.
• The Life Assured did not survive for at least 14 days after the diagnosis of: – Intermediate Stage Cancer; or – Intermediate Stage End Stage Liver Failure; or
– Advanced Stage Cancer; or
– Advanced Stage End Stage Liver Failure; or
– Diabetic Complications, as the case may be.
“Event(s) under the Special Benefit which commence, occur or are diagnosed during the waiting period of 30 days or 60 days (depending on the stage and type of critical illness) from the policy issue/reinstatement date, whichever is later.
“The exclusions highlighted here are not exhaustive. Full details are available in the policy document.”
In another brochure titled Smart Early
Payout CriticalCare, the exclusions statement is:
“No benefit is payable under the following circumstances:
• Pre-existing Illness.
• Any covered critical illnesses which commence, occur or are diagnosed during the waiting period of 30 days or 60 days, depending on the type of critical illness (except for Cancer with Severity 25 and Severity 50 where a 120 days waiting period shall apply), from the Risk Effective Date or from the date of any reinstatement of this rider or the policy, whichever is the latest.
“The exclusions highlighted here are not exhaustive. Full details are available in the policy document.”
The application forms for MySalam will be online.
The application process for those who are not internet-savvy, or who have inadequate or no access to the internet is unknown.
Patient confidentiality and consent matters in MySalam are also unknown.
Some cancer patients in Health Ministry hospitals have to purchase their own medicines as they are not listed in the Ministry’s Essential Medicines List.
The RM8,000 would be insufficient for many of these medicines. What are these patients and their attending doctors to do?
What if there is a recurrence of any critical illness, e.g. heart attack, stroke or cancer?
What will happen to MySalam after five years?
No to PeKa
PeKa comprises health screening for those aged 50 years and above in the B40 group (projected as 800,000 people on a first-comefirst-served basis), medical devices aid, incentive to complete cancer treatment and transport cost incentive, with an allocated budget of RM100mil. (See PeKa benefits)
The programme will be managed by ProtectHealth Corporation Sdn Bhd (PHCorp), a government-linked company (GLC) under the Health Ministry.
The Health secretary-general chaired a meeting with medical professional associations on Jan 10, that discussed the PeKa health screening.
The Health Ministry offered RM35 for the initial patient visit and RM30 for follow-up visit if the results were abnormal.
The doctors requested a simplified payment of RM65 for both visits, regardless of whether the blood results were normal or not.
The ministry countered with RM40 for the first visit and RM20 for the follow-up visit.
According to the medical associations, the response to their request for more details and discussion was “take it or leave it”.
The medical associations then announced their non-participation in PeKa.
According to the Private Healthcare Facilities and Services (Private Medical or Private Dental Clinics) Regulations 2006, general practitioners (GPs) are allowed to charge RM10 to RM35 for the initial, or first, consultation; RM35 to RM90 for each follow-up consultation; and RM40 to RM200 for pre-employment, routine or annual medical examinations.
Whether PHCorp is a managed care organization (MCO) was also raised. Section 82(1)(a) of the Private Healthcare Facilities and Services Act defines an MCO as “any organization or body, with whom a private healthcare facility or service makes a contract or has an arrangement, or intends to make a contract or have an arrangement, to provide specified types or quality or quantity of healthcare within a specified financing system through one or a combination of the following mechanisms: (a) delivering or giving healthcare to consumers through the organization or body’s own healthcare provider or a third party healthcare provider, in accordance with the contract or arrangement between all parties concerned.”
Going forward
The lack of transparency of MySalam and PeKa has prompted calls from parliamentarians and questions by the public, with some even asking for both schemes to be suspended.
There has been silence from the Finance Ministry.
The Health Minister has attempted to clarify the issues raised and stated that there will be meetings with relevant stakeholders to discuss their involvement in PeKa.
The Health Ministry’s approach brings back memories of the 1Care for 1Malaysia debacle.
Whether MySalam and PeKa as they currently stand, are designed for success is for the reader to judge.
Certainly, the Finance and Health ministries have to get their acts together to ensure the nuts and bolts of both schemes are put in place and that the B40 group and healthcare providers are on board for the objectives of both health schemes to be achieved. Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.