If you’ve been diagnosed with a disease lasting more than three months which is a chronic condition and you then need ongoing treatment. If the medication falls within your medical aid's chronic disease list, you then will be able to use your benefit for chronic medication. Below is a few question answered from the Council of Medical schemes which regulates medical schemes. Is my medical scheme obliged by law to provide cover for certain medical conditions? Yes, these are known as Prescribed Minimum Benefits (PMBs). They were introduced into the Medical Schemes Act to ensure that beneficiaries of medical schemes would not run out of benefits for certain conditions and find themselves forced to go to State hospitals for treatment. These PMBs cover a wide range of ±270 conditions, such as meningitis, various cancers, menopausal management, cardiac treatment and many others, including medical emergencies. However, take note that certain limitations could apply, such as the use of a Designated Service Provider and specified treatment standards. PMB diagnosis, treatment and care are not limited to hospitals. Treatment can be received wherever it is most appropriate, including a clinic, outpatient setting or even at home. Always check your benefits with your medical scheme and make sure you have the scheme's rules at your disposal. Is it true that schemes now also have to provide chronic medication? Yes, the list of PMBs includes 25 common chronic diseases in the Chronic Disease List (CDL) and other chronic conditions within the ±270 Diagnosis Treatment Pair (DTP) section. Medical schemes have to provide cover for the diagnosis, treatment and care of these diseases. However, you should remember that a medical scheme does not have to pay for diagnostic tests that establish that you are not suffering from a PMB condition. The treatment algorithms (guidelines for appropriate treatment) for each of the CDL chronic conditions have been published in the Government Gazette while the chronic diseases in the DTP section are guided by the public sector protocols. This assures you of good quality treatment and reassures your medical scheme that it will not have to pay for unnecessary treatment. Your doctor should know and understand most of the guidelines so that he or she can help you get the treatment you need for any of these conditions without incurring costs that your scheme does not cover. Why are some chronic illnesses covered and some not? The diseases that have been chosen are the most common, they are life-threatening, and are those for which cost-effective treatment would sustain and improve the quality of the member's life. Does my scheme need to do anything to ensure that the Designated Service Provider can treat me? The Council for Medical Schemes has been advising medical schemes to enter into contracts with any DSP they choose, especially State hospitals, to ensure that these providers can supply the necessary services. Many State hospitals have set up separate wards to serve beneficiaries whose treatment and hospital stay is paid for by their medical scheme and to whom the hospital can then afford to provide better service. Other schemes have made arrangements with private hospital and certain retail pharmacies to treat their beneficiaries. Can I be refused cover for the chronic conditions if I do not get authorisation or have certain tests? Yes, medical schemes can make a benefit conditional on you obtaining pre-authorisation or joining a benefit management programme. These programmes are aimed at educating members about the nature of their disease and equipping them to manage it in a way that keeps them as healthy as possible. For example, many schemes offer treatment through groups that manage diseases such as diabetes, and are equipped to give the medication and monitor that disease. To register for your Chronic medication please contact Namhla in our Health Department email health@daberistic.com , tel (011)658 -1333 Source: Council for Medical Schemes
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AuthorKevin Yeh Archives
January 2025
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