Prostate cancer – Am I covered?

Gillian Bruce, a senior case manager, answers imperative questions regarding prostate cancer and what medical aids will cover.

A prostate cancer diagnosis is overwhelming and it’s hard to come to terms with not only for you, the patient, but for your family as well. Then there is the added stress of whether your medical aid will cover your treatment. This is why it’s vital to know what your Oncology Benefit includes as many only find out when treatment is declined.

It’s also important to find out more about your type of cancer and whether it’s a prescribed minimum benefit (PMB) and the details of the cover you have. Ensuring you, your doctor and your case manager work together is part of parcel of this.

Is there screening for prostate cancer?

Yes, screening (prostate specific antigen test or digital rectal examination or both) every year is vital for early detection in males 45 years and over, and if there is a familial history from 40 years of age. 

How is prostate cancer screening paid through a medical aid?

Most screenings are paid from a medical aid’s Insured Benefit or Preventative Care Benefit.

What should I do if I’m diagnosed?

If you’re diagnosed, discuss your treatment options with your treating doctor and what the possible costs involved are. Contact your medical aid and find out the benefits you have available, which protocols may be used and if any specific limits, Designated Service Providers and co-payments may apply. 

If required and affordable, discuss upgrading your medical aid plan. Some schemes allow upgrading on diagnosis of a life-altering diagnosis while others will only allow changes in December for the following year. 

It’s also imperative to know when your benefit cycle starts and ends. Some schemes work from January to December while others work from the date of diagnosis. 

Keep track of your statements; claims are often paid from the incorrect benefit due to error or due to the incorrect ICD10 diagnosis code  used. Know your ICD10 codes and insist the correct code is used on all related accounts. This will prevent running out of day-to-day benefits. 

Once diagnosed, you should go back to all diagnostic tests that were done and get them reprocessed to pay as either prescribed minimum benefits or from the Oncology Benefit.

Find out what your schemes full exclusion list is; you would have to ask for this annexure to be sent to you, as the list on the brochure is not the full list of exclusions of treatment or drugs. 

What is a PMB and how does it affect me or my accounts?

Prescribed minimum benefits are 206 diagnoses as set out by The Department of Health and The Council of Medical Schemes (CMS). This ensures that when you have one of these 206 diagnoses, you’ll get the minimum care that is available in a state facility, paid in full regardless of benefit limit or benefit type. This would include a Hospital Plan. 

Most schemes will deplete your available benefit first and then pay what is a PMB. However, PMB should never be paid from your Medical Savings Account or accrue to your self-payment gap. Again, ensuring the correct ICD10 code is used is vital to ensure the correct accounts are paid from the correct benefits. 

It’s important to remember that you can have a PMB diagnosis, but the treatment requested is not PMB. This would mean that the treatment would either be paid from benefits available or paid from your own pocket. Some schemes will continue paying but a co-payment would apply to all non-PMB treatment. 

If my diagnosis is a PMB, can my medical aid prescribe the preferred treatment and facility?

The short answer is yes. CMS rules dictate that a scheme may insist on the allocation of a Designated Service Provider for treatment and a Drug Formulary and it can be enforced. It’s important to remember that you do have a choice. Should you choose to go out of network or off formulary, a co-payment in either rands or percentage of cost will apply. This is where it’s important to educate yourself regarding your benefits; it will prevent financial toxicity of out-lay of money for co-payments.

What do I do if my treatment is denied by my medical aid? 

It’s important to discuss the cost implications and possible financial toxicity with your family and your doctor. Remember you and your family still need to live every month with the added cost of upgrading, co-payments or treatment costs. You could choose to pay a co-payment, if part of your treatment is approved. 

Educate yourself about the available patient support and resources like The Access to Innovative Care Foundation (AICF). They assist with co-payments for some treatments. There may also be drug trials that are available for eligible patients. 

This is also where Gap Cover becomes vital at preventing co-payments with surgeries and procedures, and in some cases, cancer treatment. You can also opt to pay for the treatment yourself, however, please remember to make informed decisions that aren’t financially toxic to you now or in the future. 

Ask your scheme or doctor if they have a case manager who can help you navigate this difficult journey and always stay informed about your choices and costs.

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