Understand your hospital plan

A recent rant on Twitter by a Discovery Health Medical Scheme member highlighted an often misunderstood fact about hospital plans: They don’t cover visits to the emergency room (ER).

Many hospitals have outsourced the function of the emergency room to private practice, which means they do not actually form part of the hospital, so being admitted to hospital is different to being treated in the casualty ward.

Discovery Health says: “One is treatment as an in-patient and the other is an out patient or out-of-hospital treatment, regardless of whether the casualty rooms are based at the hospital. When a member has a planned admission for treatment in hospital, they will be admitted into a ward. A member can also be admitted into the ward from the casualty facility should the casualty doctor deem this to be necessary. When a member is admitted into hospital, they will be taken to a ward and authorisation will be obtained from the scheme. In the instance where a member is treated in the casualty rooms and thereafter able to go home, this is not an admission. This is treatment that was received via an out-patient facility.”

While this issue is particularly relevant to members of hospital plans, the same rules would apply to a member when the medical savings account has been depleted. Unless the scheme offers a specific emergency benefit, the visit to the ER would be paid from your medical savings account, so if the funds are depleted, you would have to pay out of your pocket.

However, medical schemes are obliged to cover emergencies as part of prescribed minimum benefits (PMBs) and if the member is admitted to the ER for a genuine emergency, it could be covered under the hospital plan. However, what constitutes an emergency is not always clear.

Damian McHugh, head of health marketing and growth at Momentum, acknowledges that this can be confusing for members who, when they go to the ER, do not know if their bills will be covered by their hospital plan.

“If we fully covered all visits to the ER, people would abuse it and use it for day-to-day events that are not covered under a hospital plan,” says McHugh, who adds that, as a general rule, if you are on a hospital plan and you visit the ER, you won’t be covered by your medical scheme.

Some hospital plans may provide for a limited number of consultations at medical practices, which can mean that, in some cases, your ER visit may be covered, so you need to read your benefit guide for clarification.

“It is important to note that there are instances where a medical scheme’s definition of an emergency differs from that of a consumer’s – which the consumer won’t reasonably know as general knowledge,” says McHugh.

For example, if you fall and bang your head and require stitches, that may not be considered to be an emergency. However, if you are vomiting and concussed and need an urgent medical examination, that could be an emergency – even if you are able to go home the same day without being admitted to hospital.

“From a medical scheme’s perspective, we can only rely on the code we receive from the ER to determine whether or not it was considered an emergency,” says McHugh.

That doesn’t mean that you cannot question the decision, and if you feel that it was a genuine emergency, you need to contact your medical scheme to argue your case.

According to Discovery Health, members can complete the out-of-hospital management of a PMB condition form, where the casualty account can be reviewed for cover.

Dr Jonathan Broomberg, CEO of Discovery Health, says: “Cover for these acute out-of-hospital PMB conditions, which are typically once-off events, requires an application for funding following the event. This application process is necessary as the information initially received by the scheme with the first claim is generally limited to the ICD-10 and tariff codes on the claim only. This information is not sufficient to establish a reliable diagnosis and the scheme often requires additional clinical information or confirmatory evidence to determine whether the circumstances of the case actually meet the definition
of a PMB or an emergency PMB.”

He says that, when the scheme becomes aware of the ER visit after the event or is subsequently informed that the event qualified as an emergency, all claims related to the admission are reviewed and processed in accordance with the PMB regulations.

Emergency rooms charge much higher fees than your local GP, so you need to consider carefully whether there is a genuine emergency before you rush yourself or your child to the ER. A good rule of thumb is to know whether or not your local GP would be able to attend to the problem.

A heart attack, broken limb or car accident where you are brought in by ambulance would most likely make the emergency list. If your GP refers you to the ER, there’s a good chance the visit would be covered.

It is worth noting that some schemes provide cover for non-PMB emergencies. For example, Fedhealth offers its members unlimited trauma treatment at a casualty ward, paid at 100% of the Fedhealth rate with a co-payment of R570 per non-PMB visit.

Understand your hospital plan

Hospital plan benefits vary between medical schemes, so it is important to understand what cover you have or don’t have. Hospital plans pay at different in-hospital rates – for example, some pay only 100% of the medical scheme rate, while others pay 200%. You also need to check how many PMBs are covered by your hospital plan.

Jill Larkan, head of healthcare consulting at advisory firm GTC, says some schemes offer benefits above the 26 PMB chronic illnesses and may include additional preventive or primary healthcare.

“Sixty-one percent of all hospital plans provide prenatal maternity consultations from risk, even though they are pure hospital plans, while 32% provide postnatal consultations and 46% even provide paediatric consultations,” says Larkan, who adds that 34% of hospital plans offer contraceptive benefits as well, even though these have nothing to do with hospitalisation, and that 22% of plans offer specialised radiology cover outside of hospital.

You also need to check what post-hospitalisation benefits you receive. For example, you may have been admitted to hospital after a car accident and require physiotherapy after being discharged. As this would be an out-of-hospital treatment, it would not fall under hospital treatment. Some hospital plans include a 30-day rehabilitation benefit, so make sure you know what cover you have and what you don’t have.

Also be aware of exclusions on your hospital plan. For example, most hospital plans will not cover cosmetic procedures, frail care or self-inflicted injuries. There may also be copayments on elective procedures such as a hip replacement.

“Authorisation is the key to getting the best cover from your medical aid. You will also find that, for elective procedures, you, your doctor and the hospital all end up phoning the medical aid for an authorisation reference number for the procedure. This is good for members because, should the elective procedure carry a copayment or not be covered because of a general or plan-specific exclusion, you will find out at that point. The authorisation note will state this and list the co-payment amount,” says Larkan. 

	Maya Fisher-French Personal finance journalist City Press p: 0117139001 w: www.mayaonmoney.co.za  e: maya@askmaya.co.za
Sign up for City Press' morning newsletter On a Point of Order here

 

---

---