Benefits can become complicated. For your own good, here’s what you should know. Medical schemes undertake liability in return for a premium or contribution. They are required to help their members in obtaining healthcare services and defraying expenditure for such services. The benefits that a scheme may grant must be registered in its rules. Schemes typically cover the following healthcare services:
Common tariff structures
Private health insurance allows people to protect themselves from the potentially extreme costs of medical care if they become ill. It also gives people access to healthcare when they need it. The exclusion list of scheme options (Annexure C of scheme rules) deals with limitations of entitlements. Schemes must ensure that there is good reason for these exclusions and limitations, and that they are not too broadly worded. Otherwise, they may lead to arbitrary or unreasonable denial of care. But why exclusions and limitations? Entitlements in any option are discretionary (optional) or non-discretionary (compulsory). The latter are covered by the prescribed minimum benefits (PMBs). The Regulations in the Medical Schemes Act 131 of 1998 deal with the entitlement to PMBs: they must be paid in full under certain circumstances, such as when the member obtained the service from a designated service provider. The standard of care (and entitlement to it) is determined by protocols based on the principles of evidence-based medicine or, where these do not exist, the protocols of the public sector. Non-PMB conditions and entitlements are dealt with in scheme rules, and limitations and exclusions are applicable to them. Exclusions The following principles should be considered when deciding whether an exclusion is justified or not: best practice, evidence-based healthcare, clinical protocol, cost-effectiveness (affordability), and the laws of the country.Conditions or circumstances that should definitely not be excluded are those that are medically necessary, with little discretion from the member and/or service provider. Put differently, consider whether urgent treatment is needed to prevent death or permanent disability, and whether the attending doctor has some discretion as to the timing of treatment, and whether the treatment should be given at all. It would, for example, be entirely inappropriate to include an exclusion for the treatment of acute appendicitis, whereas an exclusion for cosmetic surgery in the absence of clinical indications would be appropriate. Not forgetting affordability, clinical protocols based on evidence-based medicine should be the bottom line when deciding whether funding is justified or not. Fair exclusion? You decide. Limitations on cover are appropriate where they permit a degree of financial risk management. But they are inappropriate where their application allows for the selective targeting of specific people or vulnerable risk groups. Thus, reasonable financial management should be permitted, but not to the extent that it allows risk selection and unfair discrimination. Limitations should be permitted where they achieve the following:
Limitations are inappropriate where they achieve the following:
Source: Medicalaide.co.za
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