A MEDICAL AID MUST SUIT YOUR NEEDS

Peter Edwards- Alexander Forbes

Navigating your way through the confusing maze of medical aids starts with the selection of the scheme.
Peter Edwards, managing director of Alexander Forbes Health, says this decision should include issues of stability and solvency of the scheme, and the innovation and service levels applied by the administrator of the scheme. "Preferably you'd want the solvency level to be around where the regulations require it to be, around 25% of premiums. Anything below that means that means schemes ultimately are under pressure to move to that level, and they have to price in reserve growth" says Edward. "You don't want a scheme that's losing a lot of money, because it would mean having to correct this position with benefit reductions and/ or significant contribution increases."
Look for stability, not a scheme that makes a lot of money one year and loses the next, or has significant changes to its options. Look at past contribution increases. This will tell you whether the scheme is stable and whether increases are introduced in a consistent manner.
"Generally an indicator of stability is size. A larger medical scheme is likely to be more stable and the experience is fairly consistent, given the larger risk base. In a large scheme, one big claim or a series of big claims don't have an impact on the scheme, unlike small schemes where it could be detrimental," says Edward.
It's difficult for an individual who's not directly involved in the market to assess the administrator. That's where the financial adviser, your doctor, and family and friends come in. Another important point is governance. "You don't want a high noise factor around a scheme, with infighting splashed in the press. You want a low noise factor. It mostly indicates things should be going well and that there's stability and it's organised." The base of any medical scheme is prescribed minimum benefits, which schemes are required to cover by law. You must ensure that you choose the scheme with the hospital cover you require. if you rarely go to a doctor, you might be happy with a hospital plan only or savings- based option.
All options have to cover 26 chronic conditions as part of the prescribed minimum benefits. If you have a chronic condition which is not on the list, you will need to consider higher- level options covered by a scheme. Edward suggests evaluating the cost of this additional cover versus covering the cost of your own medication, as it may be less than the additional cost of buying up.
"If your day-to-day needs are higher, such as if you have a health condition or young children, then maybe consider a medical scheme that has more comprehensive benefits than just a savings account or minimum out-of-hospital cover. Perhaps consider one that has an above- threshold benefit or more comprehensive benefits.
"It helps to try and estimate how much you'd need for out-of-hospital costs and take this into account when selecting your option.
"A real problem for people is the detail within a scheme. People often just gloss over it, but it creates massive frustration."

Look at these elements to better understand the detail:


* The first is chronic medication. Can you get medication from anywhere ir do you have to go to a specific network? Most of teh bigger schemes have networks where you can see specific practitioners or get medicines from particular places. In return, you pay less and have the comfort that prescribed minimum benefits will be covered in full.
"Familiarise yourself with those networks. A lot of people don't, and then benefits aren't paid in the way they expected," says Edward
* Affordability is a critical issue and needs to be taken into account in making your selection.
Network plans or lower- cost options often aren't understood. They are not sub- standard. This is clear if you look at the number of doctors that agree to be part of the network. "If affordability is an issue, join a different structured plan."
When getting advice, there are three key things you need to make sure advisers are doing for you:
- First, they must do a thorough needs analysis and ask you about your health status. Are you planning to have a baby? When were you last in hospital?
- They must make their recommendations and indicate why they're suggesting one scheme and plan, and not another;
- If an adviser suggests that you move, he must communicate the differences between where you come from and where you're going, to such as how the contributions and procedures differ.

How prescribed minimum benefits help you manage diabetes

What is diabetes mellitus?

When we eat, the food is broken down into materials that our bodies need to function properly. One of the substances into which food is broken down is the simple sugar glucose. Sugar is absorbed into the bloodstream and stimulates the pancreas to produce insulin. Insulin allows sugar to move from the blood into the cells where it is converted into energy.

Diabetes is a chronic disease where your blood sugar levels (blood glucose) are too high because the normal control mechanisms of your body fail.

There are two types of diabetes, namely type I and type II. The two types are actually two completely different diseases.

Diabetes type I occurs when your body does not produce adequate quantities of insulin. It typically starts in early childhood.

Diabetes type II occurs when your body does not make enough insulin or, even if adequate amounts of insulin are produced, the body fails to transport the glucose from the bloodstream into the body cells. Type II usually starts later in life.

The result of both is that the glucose stays in your blood and cannot be used as an energy source for normal cell functions.

Diabetes leads to serious complications and could even jeopardise your life. It may cause heart disease and strokes and damage the eyes, kidneys and nervous system. Blood sugar levels that are too high or too low can also cause you to fall into a coma.

Diabetes cannot be cured but it can be successfully managed.

Treating diabetes

The treatment of diabetes focuses on the control of blood sugar levels. Treatment involves all aspects of your lifestyle, especially diet and exercise, but most sufferers also use medicine management at some point.

People with diabetes mellitus type I almost always need insulin therapy but lifestyle management is still important. People with diabetes mellitus type II may be able to manage their disease with lifestyle changes but if blood sugar levels cannot be controlled this way, oral anti-hyperglycaemic drugs and even insulin therapy may be required. Treatment of other risk factors such as blood pressure and high cholesterol is extremely important.

PMB entitlement

Diabetes mellitus type I and type II are included on the prescribed minimum benefit (PMB) Chronic Diseases List. This means that your medical scheme must fund the diagnosis, treatment and care of your condition and it must do so from its risk pool and in full.

Your condition must be treated according to the algorithm in the PMB regulations. These algorithms are also available on the Council for Medical Schemes (CMS) website at the following links:
http://www.medicalschemes.com/files/Prescribed%20Minimum%20Benefits/DiabetesMellitus1_2.pdf
http://www.medicalschemes.com/files/Prescribed%20Minimum%20Benefits/DiabetesMellitus2_3.pdf

The disease management interventions that must be funded by the scheme include:

• Consultations with your treating provider (GP or specialist – if authorised by your scheme)
• Lifestyle modification interventions such as dietary and disease education
• Annual eye examination for retinopathy
• Annual comprehensive foot examination
• Pathology tests at 3-6 monthly intervals
• Disease identification card or disc
• Home glucose monitoring

It is important to remember that the scheme may still use managed care protocols which for instance allow only a specific number of consultations with your treating provider per year. These protocols must be supplied to you on request.

If there is a clinical reason or need for more benefits than those specified in the protocol the medical scheme may not refuse to fund these.

The Communications Unit would like to thank Ronelle Smit, Dr Nkuli Mlaba, Dr Selaelo Mametja and Dr Boshoff Steenekamp for making this edition of CMScript possible.

Clarity on PMB's

Carte Blanche on MNET had a slot last Sunday on Prescribed Minimum Benefits which might have caused some confusion.




Just to get more clarity on the PMBs as introduced into the Medical Schemes Act


· PMB’s was introduced into the Medical Schemes Act to ensure that members 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 close to 300 conditions, such as meningitis, various cancers, menopausal management, cardiac treatment and many others including medical emergencies.


· Terminology


In order to understand the impact of the legislation changes, a clear understanding of the terminology is required:


Designated service provider (DSP)


This refers to health care provider/s that have been "selected by the scheme to provide its members diagnosis, treatment and care in respect of one or more of the PMB conditions".


Emergency medical condition


This is a medical condition which is of sudden and unexpected onset that requires immediate medical or surgical treatment. Failure to provide this treatment would result in impairment of bodily functions, serious dysfunction of a bodily organ or part, or would place the person's life in serious jeopardy.


Prescribed Minimum Benefits (PMB's)


PMB's are minimum benefits which by law must be provided to all medical scheme members and include the provision of diagnosis, treatment and care costs for:


· any emergency medical condition
· a range of conditions as specified in Annexure A of the Regulations to the Medical Schemes Act (No 131 of 1998), subject to limitations specified in Annexure A. Included in this list of conditions is the list of chronic conditions


So this means that a long list of conditions identified as Prescribed Minimum Benefits was issued. The list is in the form of Diagnosis and Treatment Pairs (DTPs). A DTP links a specific diagnosis to a treatment and therefore broadly indicates how each of the approximately 270 PMB conditions should be treated. The treatment and care of PMB conditions should be based on healthcare that has proven to work best, taking affordability into consideration. Should there be a disagreement about the treatment of a specific case, the standards (also called practice and protocols) in force in the public sector will be applied.


The treatment and care of some of the conditions included in the DTP may include chronic medicine, e.g. HIV-infection and menopausal management. In these cases, the public sector protocols will also apply to the chronic medication.

10 Reasons to have a good Medical Scheme.

by SAPA


Think about a medical worst-case scenario. You’re trapped under a truck, your head is bleeding and you are sure your leg is broken in at least one place. There are sirens, ambulances, the fire brigade, and the last thing you remember before waking up in the ICU is being put on stretchers.

This type of accident scenario is what most people think of when they think of reasons why a medical scheme is necessary. And let’s face it, under these circumstances, good medical care could save your life.

And yes, medical schemes and hospital plans are expensive, but it might be even more expensive not having one.

But being well cared for after accidents is not the only reason why having a medical scheme is important. Here are some others.

The end-of-the month flu bout. It’s three days to payday and you’re down to your last R20. You’re going to be living on potatoes and the smell of an oil rag for the next 72 hours. And then you get ill. Very ill. Your chest is rattling, your head is so sore it feels like it wants to part company with your body, and you have forgotten what it is like to breathe through your nose. And your doctor works on a cash-basis only. Except if the account is sent directly to your medical scheme. Need I say more?

Sudden expensive medication. For the same flu bout, you need medication from the chemist – and it doesn’t come cheap. In fact, even with opting for the generics, the total bill for this comes to R237,11. And right now, you just don’t have it. But fortunately your chemist sends the bill to your medical scheme and you end up having to pay a levy of a few rand. Now that you can do.

Serious diseases. Cancer, emphysema, diabetes complications, ongoing heart problems – these are things no one ever thinks will happen to them. But when they do, and the onset could be sudden, the cost of things like scans, X-rays, pathology tests, ultrasounds could run into thousands. Not to speak of lengthy hospitalisation and expensive operations. And few people have that kind of money lying around. Most medical schemes and hospital plans will cover these things in full.
The young and the old. Few people use their medical schemes much when they are in their twenties, or even thirties. But their contributions make a big difference to funding the medical costs of the older members. And young people get older, and one day their costs will be funded by new and incoming younger members. And no, it is not a solution to join when you retire, as your premiums will be much higher than those of someone who has been a member for twenty years. This is understandable. And a medical scheme is essential for retired people – this is probably going to be when you need it most.

Eye problems. Welcome to your forties. Here is your complimentary pair of reading glasses. Not really, but you get the picture. Few people get past middle age without some vision problems. These can range from minor to serious – and prescription lenses (even with cheaper frames) don’t come cheap. And you might need new ones every two years.

Not state-of-the-art hospitals. While there are some state hospitals that are fine, in fact, downright fantastic, there are major funding and staffing problems in many of them. In several of the hospitals the actual operations performed are excellent, but the problems come in with post-operative care of patients. While not all private hospitals are completely fantastic, the level of care you receive and the facilities available to you are likely to be better. And so it should be, because most of them are jolly expensive. If your life is hanging by a thread, the last thing you feel like dealing with are no sheets on the bed or dirty toilets. Or waiting endlessly in a queue while you are bleeding. So pay your medical scheme contribution with a smile.

Peace of mind. We spend an inordinate amount of our time worrying about money. If you have a family, and are a wage earner, unless you have won the lottery, you would not be able to foot the bill if your family of five were in the same car accident and all landed in hospital. Whereas medical schemes do have limits, most hospital costs are at least paid for. So now you can sleep at night.

Ambulances. If you’ve had a heart attack and are lying on the floor of a restaurant, you want the ambulance to get there without delay. Sometimes state ambulances are very swift, but there are also horror stories about badly injured or ill people waiting hours for an ambulance. Being a member of a medical scheme usually entitles you to use a private ambulance.

Maternity costs. Having a baby is expensive - even if there are no complications. Medical schemes will not cover you for your pregnancy if you only join once you are pregnant, so if you are planning to have a family, and you’re not a member yet, make a plan as soon as possible.

Check-ups. You know you should go to the dentist, the oral hygienist, the GP or the homeopath for regular check-ups. But you don’t, because it is expensive. You wait until something goes wrong, and then you go. And it ends up costing you three times as much. Prevention is indeed better than cure. And within specific limits, your medical scheme will pay for these check-ups.

Medical Aid... A Necessity?

I believe that its time to chat about medical aids and what we expect of a medical aid. Medical aids are like cars, the smaller and cheaper the car, the less “gadgets” or “add-ons” are available. So when paying R300 per month for a medical aid, you cannot expect to get the same benefits as a person that pays R3000 per month for a medical aid.

In saying the above I need to also explain that there’s benefits that schemes are obliged to pay even if you are on the cheapest option available. These benefits are called “Prescribed Minimum Benefits” , the there’s currently 270 of these and they are listed on the Council for Medical Schemes website: www.medicalschemes.com

Should you want me to discuss these in detail, I am quite happy to do so.

Let’s now talk about the various types of medical aids available. In general there’s Open Schemes and Closed Schemes.

Closed Schemes are schemes where membership is available to only certain members. Ie Sasolmed – only Sasol Employees can belong to Sasolmed.

Open schemes are schemes where membership is open to anyone that applies. Contributions can only take into account the option on the scheme selected, family size, income (this is not applicable on all medical schemes). One other factor that may affect your premium would be the “Late Joiner Penalty”, this only applies to people who have not been on medicals schemes for long periods of time.

I believe that it’s a necessity as care in public facilities are not what its meant to be due to shortage of skilled staff, facilities not well looked after etc. Hence the whole debate around NHI (National Health Insurance)

When selecting a medical scheme there’s some important factors that need to be taken into consideration.

• Solvency level of scheme

• Size of scheme – ie has membership grown?

• Claims paying ability of scheme

• Average age of the scheme, is the scheme attracting younger members?

• Average increases over last 5 years

• Administration, will it be easy to deal with the scheme, ie do they keep you updated with any status of your claims?

• Selecting an appropriate broker/ financial planner that knows the industry and can assist when you don’t understand the workings of a scheme, or when you struggle to get claims paid.

Don’t wait till you get sick to join the medical aid. Every medical scheme has the right to apply 3 months general waiting period and/or 12 month conditions specific exclusion.

What if you get in a car accident? Do you want to lie in a long que waiting to be treated in a public facility? If cost an issue, join a hospital cover option to start off with, at least you’ll have full cover when hospitilised.