Medical schemes – the basics
Elsabé Klinck educates us on the basics of medical schemes when affected by cancer.
Medical scheme cover
The jargon of medical schemes can easily confuse patients, or the loved ones of cancer patients. Apart from choosing between various plans, there is a bewildering array of types of benefits (e.g. oncology benefits with or without co-payments); divisions into chronic, savings and/or risk pools; thresholds; payment gaps; co-payments and the likes.
The law, however, creates a ‘fairly’ straight-forward system, where schemes:
- must offer so-called Prescribed Minimum Benefits (PMBs) which must always be funded.
- may offer other healthcare cover for other conditions, not included in the PMBs.
There is, in law, no such thing as a ‘hospital plan’. This is sometimes used to describe a benefit package that provides mostly PMB care. Although the PMBs could be delivered, and some care must be delivered in a hospital (such as operations to remove cancerous growths), the law is clear that the PMBs don’t describe a setting, and care can be rendered in any appropriate setting.
It’s therefore unfortunate that some medical schemes require hospital admission prior to funding certain investigations or care. This unnecessarily increases the cost of care.
Non-medical scheme cover
Apart from medical schemes, persons can also take out certain insurance products to cover the eventuality of ill health. Two of the best-known products are:
- Dread-disease cover
- Gap cover
These types of cover don’t pay for the care of the condition, e.g. doctor visits, medication, etc., but rather pays out a lump sum, or covers the financial gap not covered by a medical scheme.
Whereas medical scheme cover is always measured against what would be appropriate, or in line with evidence-based medicine, non-medical scheme cover is always a monetary value, and not a benefit.
The public must note that the future of non-medical scheme cover hangs in the balance. Consultations are under way to find a way forward that will protect the public by ensuring appropriate cover for healthcare needs, whilst ensuring, in particular, the availability of low-cost options that covers basic care, such as GP visits, or basic medicines for members of the public who can’t afford medical schemes.
PMBs
Most of the PMBs were added to the law to ensure that catastrophic high-cost care is covered. Individuals can’t cover these types of care cases,and therefore requires the benefit of a shared funding pool.
PMBs must always be funded from a common shared risk pool. It means that, irrespective of one’s contributions, the PMB pool must fund those conditions according to one’s needs. So, in any particular year, some persons may claim less, and others more, to ensure that each person’s needs are met.
There are 270 PMB conditions listed in an annexure to the Regulations to the Medical Schemes Act. It also includes all emergency conditions, such as when patients with a low white blood cell count falls significantly, and care is needed immediately to save the person’s life.
The PMB conditions contain a so-called PMB code, a description of the condition and then a description, in broad terms, of what a medical scheme must cover.
It’s important to note that all PMB conditions must be funded in full on all options. Patients don’t need to upgrade, or change their plans, because of the PMB treatment they require. Medical schemes can’t run out of PMB benefits, as it’s covered through a shared risk pool.
PMB cancers
It’s important to know whether a cancer is a PMB cancer or not. Patients must bear in mind that the PMBs haven’t been updated, as is required by the law every two years, and some of the descriptions in the annexure (below) are now outdated, and can be successfully challenged to obtain appropriate care and cover for such cases.
| 951K | Benign and malignant tumours of pituitary gland with/without hypersecretion syndromes | Medical and surgical management; radiation therapy |
| 950A | Benign and malignant brain tumours, treatable | Medical and surgical management, which includes radiation therapy and chemotherapy |
| 950B | Cancer of eye and orbit – treatable | Medical and surgical management, which includes radiation therapy and chemotherapy |
| 950C | Cancer of oral cavity, pharynx, nose, ear, and larynx – treatable | Medical and surgical management, which includes chemotherapy and radiation therapy |
| 950D | Cancer of lung, bronchus, pleura, trachea, mediastinum and other respiratory organs – treatable | Medical and surgical management, which includes chemotherapy and radiation therapy |
| 952F | Cancer of retroperitoneum, peritoneum, omentum and mesentery – treatable | Medical and surgical management, which includes chemotherapy and radiation therapy |
| 950C | Cancer of the gastro-intestinal tract including oesophagus, stomach, bowel, rectum, anus – treatable | Medical and surgical management, which includes radiation therapy and chemotherapy |
| 950G | Cancer of liver, biliary system and pancreas – treatable | Medical and surgical management |
| 950H | Cancer of bones – treatable | Medical and surgical management, which includes chemotherapy and radiation therapy |
| 950J | Cancer of breast – treatable | Medical and surgical management, which includes chemotherapy and radiation therapy |
| 954J | Cancer of skin, excluding malignant melanoma – treatable | If histologically confirmed, medical and surgical management, which includes radiation therapy |
| 952J | Cancer of soft tissue, including sarcomas and malignancies of the adnexa – treatable | Medical and surgical management, which includes chemotherapy and radiation therapy |
| 950K | Cancer of endocrine system, excluding thyroid – treatable | Medical and surgical management, which includes chemotherapy and radiation therapy |
| 952K | Cancer of thyroid – treatable; carcinoid syndrome | Medical and surgical management, which includes chemotherapy and radiation therapy |
| 954L | Cancer of penis and other male genital organ – treatable | Medical and surgical management, which includes chemotherapy and radiation therapy |
| 953L | Cancer of prostate gland – treatable | Medical and surgical management, which includes chemotherapy and radiation therapy |
| 950L | Cancer of testis – treatable | Medical and surgical management, which includes chemotherapy and radiation therapy |
| 952L | Cancer of urinary system including kidney and bladder – treatable | Medical and surgical management, which includes chemotherapy and radiation therapy |
| 954M | Cancer of cervix – treatable | Medical and surgical management, which includes radiation therapy and chemotherapy |
| 952M | Cancer of ovary – treatable | Medical and surgical management, which includes chemotherapy and radiation therapy |
| 950M | Cancer of uterus – treatable | Medical and surgical management, which includes chemotherapy and radiation therapy |
| 953M | Cancer of vagina, vulva and other female genital organs – treatable | Medical and surgical management, which includes radiation therapy and chemotherapy |
| 960M | Cervical and breast cancer screening | Cervical smears; periodic breast examination |
| 937S | Tumour of internal organ (excludes skin): unknown whether benign or malignant | Biopsy |
The challenge
The main challenge occurs with the description of ‘treatable’ next to the cancer. The definition of what a ‘treatable cancer’ is has changed since 1999, when the PMB list was first developed. The definition no longer aligns with what evidence-based medicine (i.e. the science) tells us on whether cancers are treatable or not.
Medical and surgical management
Because of the outdated definition of a treatable cancer as a cancer that has, for example, not spread, patients and their healthcare providers should ensure that ‘medical and surgical management’ is defined in line with evidence-based medicine.
The law provides a definition of evidence-based medicine as being the current best evidence, where the individual’s situation and experiences are matched with what the best external evidence, set through local and international guidelines, research and the likes.
It’s important to note that even for non-PMB cancers, the definition of evidence-based medicine apply when a scheme indicates that it does cover other cancers. So, the undertaking to fund must be scientifically-based.
Disease limits
Medical schemes frequently set disease limits on the oncology care and medicines they fund. The medical schemes regulations cover such instances. Regulation 15G reads as follows:
If managed healthcare entails limiting coverage of specific diseases—
(a) such limitations or a restricted list of diseases must be developed on the basis of evidence-based medicine, taking into account considerations of cost-effectiveness and affordability; and
(b) the medical scheme and the managed healthcare organisation must provide such limitation or restricted list to healthcare providers, beneficiaries and members of the public, upon request.
Two things are pertinent here, namely the evidence-based nature of the monetary limitations being set, and that the restrictions being placed, must be made known not only to patients, but to any member of the public.
Conclusion
Patients, and family members, should ask medical schemes about the benefits they would be entitled to, and ask specifically on the limitations, and processes through which they could appeal decisions that aren’t in their favour.
Healthcare professionals should know whether a cancer is a PMB cancer or not, and whether it would be treatable in the modern-day sense. They should motivate for care that aligns with evidence-based medicine, and assist patients or their family members in taking up funding limitations.
MEET THE EXPERT – Elsabe Klinck
Elsabé Klinck is a B.Iuris, LL.B graduate, who also completed a degree in Psychology for Applied Professional Contexts and an honours degree in German. She started her career in the Department of Constitutional Law at the Free State University, where she also worked for the Centre for Human Rights Studies, managing amongst others, voter education and paralegal training projects. Elsabé also participated in the training of Magistrates on Diversity (with the Law, Race and Gender Unit at UCT) and the training of local government councillors and Free State Peace Committees. This experience in human rights and constitutional law stand her in good stead in her health sector work.