The ins and outs of medical aid cover

2016-06-09 14:27

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

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 non-designated 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 non-designated 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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