It seems that every year medical scheme premiums go up and medical savings accounts (MSA) are used up sooner. This article will help you understand what your rights are with regard to how your medical scheme uses your savings to finance your healthcare needs.
What type of care should a medical aid fund out of your MSA?
Most medical scheme options are by law required to fund the costs related to the diagnosis and/or the treatment of specific medical conditions and to do so outside of your MSA. This is referred to as the Prescribed Minimum Benefits (PMBs). There are 270 such conditions which are defined in the Medical Schemes Act.
In addition, there are 26 chronic diseases, which are PMBs, and include:
• High blood pressure
• High cholesterol
• Heart Disease and Heart Failure
• Bipolar Mood Disorder
• Chronic kidney disease
• Rheumatoid arthritis
• Systemic lupus erythematosus
The PMBs may also include certain acute conditions such as:
• Ear infections
• Asthma attacks
• Heart attacks
• Fractures and dislocations of certain bones and joints
May the medical scheme put restrictions on the payment of PMBs?
A medical scheme can require certain conditions to be fulfilled before they fund PMBs. However, if all these prerequisites are met, the medical scheme is required to pay in full for whatever is specified in the Medical Schemes Act. The following may be required by your medical aid to process the appropriate payments in full:
• The completion and submission of paperwork and test results by your healthcare provider and/or yourself to confirm that the condition is a PMB.
• Registration of the condition as a PMB.
• The use of appropriate codes on accounts or in pre-authorisation requests by the healthcare provider.
• That you receive your care from a designated service provider or a preferred provider within defined networks.
• That your doctor prescribes medication from a defined list (called a formulary).
• That you receive a referral from a GP before consulting a specialist.
• Requiring a patient to join a specific disease management programme.
Is there a limit to benefits for a given PMB condition?
The benefits which a medical scheme is required to cover for a certain PMB are sometimes defined quite broadly within the legislation, for example, that the medical scheme needs to cover the diagnosis and treatment of a condition. Exactly which tests and interventions are covered within this may not be specified and should therefore be discussed with your medical scheme.
How can I as the patient ensure I benefit from the PMB legislation?
1. Educate yourself. This includes what conditions are covered, what parts of the diagnosis and treatment need to be covered by the law and what potential restrictions are placed on your funding by your medical aid.
2. Ensure you are registered for your condition and any appropriate pre-authorization is obtained. This usually requires you to obtain a form from your medical scheme and have it completed and submitted. Ask your doctor about this when consulting with them.
3. Ask your doctor to ensure they use the right codes when claiming for your condition.
4. Ensure you see only doctors in the provider network your medical scheme has set up. These lists can usually be obtained from the medical scheme via their website, the scheme app or customer call centre.
5. Ensure you are provided with medication which is on the list prescribed by your medical scheme. When collecting your medication from the pharmacy, ask them to provide you with medication on your medical scheme’s formulary. The medication your doctor prescribed may not always be substitutable, but your pharmacist will discuss this with you if that’s the case.