Is cancer a matter of life and debt?

René Botha gives sound advice to help you understand what your medical aid or insurance will cover and how to avoid unwanted debt.

You can listen to this article below, or by using your favourite podcast player at pod.link/oncologybuddies

Receiving a cancer diagnosis is very overwhelming. You are given a vast amount of information in a short amount of time and it’s a lot to process. As you start to process, a huge concern (for many patients) is the cost of all the tests and treatments. If you have medical aid or medical insurance, you are suddenly confronted with abbreviations, terms and conditions and many other rules you may never have heard before. That fine print you never even thought about may become your biggest nightmare. You start to ask yourself: is cancer a matter of life and debt?

To maximise your medical aid or insurance benefits, it’s important to understand the finer details, T&Cs and rules that are applied to oncology benefits. Each medical aid has an oncology benefit which makes funds available that are used specifically for the management of cancer. The benefit varies between schemes as well as which option you have selected. There are specific rules and regulations that dictate how these funds may be used. These benefits are used to fund certain tests relating to the cancer, cancer directed treatment, such as systemic therapy which includes chemotherapy, endocrine therapy, immunotherapy, targeted therapy, as well as other treatments like radiotherapy. Supportive medications that are used to combat the side effects of treatment may also be funded from these benefits. Pre-authorisation must be obtained prior to certain tests being done or treatment given.

Proof of the cancer

Upon diagnosis your medical aid will require proof of the cancer to activate the oncology benefit. This can be done by your doctor or yourself. It’s important to note that not all medical insurances have oncology benefits as they are governed by different laws to those of medical aids. As a member of a medical insurance, be sure that you know what benefits you qualify for and how they are paid out. Often there is a lump sum paid out upon diagnosis and it’s up to you to use that amount to fund your own treatment.

Designated service providers

Some medical aids have rules regarding designated service providers (DSPs). This means that the medical aid has payment agreements with certain doctors or departments to regulate costs and would prefer for you to use these providers.

It’s very important to understand that this doesn’t mean you may not choose your doctor. However, choosing a doctor or treatment centre that is not a DSP may incur a co-payment for this service.

When you choose your doctor or treatment centre, ask upfront if they are a DSP for your medical scheme and if not, will there be co-payments for your treatment. Some providers are willing to accept the DSP rates and will not make you liable for the balance. However, in some circumstances this is not possible and may result in high out-of-pocket expenses for you. This allows you to make informed decisions about possible financial implications prior to committing to treatment and incurring unknown costs.

Treatment plan approval

Each medical aid follows specific guidelines to determine which tests and treatments are appropriate for each case. These are not only specific to your condition but may also be affected by which option and scheme you belong to. The treating oncologist must submit a treatment plan to the scheme which will be evaluated by a case manager to see if it conforms to the scheme rules and protocols for authorisation. The protocols are broken down into different levels, depending on the clinical indication as per international guidelines as well as the cost and complexity of treatment. For higher level treatments or in the case of an ‘off protocol’ treatment, the plan is referred to a medical advisor or review board.

Prescribed minimum benefits

The basic level of treatment is easily approved at case manager level. This is known as prescribed minimum benefits (PMBs) and is based on the guidelines from The Council for Medical Schemes and is the basic level of care that any person in the country should have access to, whether they are treated in a state facility or funded on a medical aid. These PMB treatments should not carry any co-payments. If your oncology benefit is exhausted, PMB level treatment should still be covered in full. If you are in the position of having exhausted your oncology benefits, ask your doctor if the treatment you are receiving is PMB level and then ensure that the medical aid processes these costs appropriately.

Innovation comes at a high cost

Research into improving cancer care and outcomes is ongoing. Newer drugs are developed as well as improvements in surgical techniques and newer technology in the radiotherapy field. All in the effort to improve the efficacy of treatment, reduce side effects and improve survival for cancer patients. As a result of this ongoing research, new systemic therapies and improved radiotherapy techniques come into play. These new developments unfortunately come at additional costs, sometimes significant additional cost.

Very often these newer drugs and technologies aren’t included in the PMB level of care and aren’t readily available to all South Africans because of the high financial burden. When application is done for these treatments, it’s referred to the medical aid or advisory committee for review prior to approval. While these treatments in certain cases may be clinically appropriate and even recommended as standard of care in some international guidelines, the medical aids may decline these treatments or authorise them with substantial co-payments.

Your medical aid should inform you, if there is going to be a co-payment and what the value of that co-payment will be. As a patient you should obtain the estimated costs from your doctor prior to treatment and then ask your medical aid if that amount will be paid in full or if there is going to be any shortfall. You can then discuss this with your treatment team to establish what you will need to pay and when so that you can plan appropriately.

Gap cover to the rescue

Gap cover may be helpful in the event of co-payments for treatment. Depending on the gap cover insurance you have purchased, there may be benefits available to assist with these costs. Check your cover and make sure you know how to claim these benefits.

Waiting for authorisations

Obtaining authorisation for treatment takes time. For a standard treatment plan, the turnaround time for approval is anywhere between 24 hours to five working days.

In the case of an emergency, PMB treatment may be initiated while the authorisation process is being done. However, for higher level or ‘off protocol’ treatments, the authorisation period can be significantly longer. The review process can take days to weeks. This delay in treatment will be a very stressful time for you. It may be at the beginning of treatment or once you have finished one course of treatment and are preparing for another.

When possible, the treatment team will obtain authorisation for the next course of treatment prior to completing the first to avoid delays in treatment, however, sometimes this isn’t possible. The scheme may require the submission of test results after the first course prior to reviewing the next course for approval. Sometimes adjustments may need to be made in planned treatment if there are complications or changes in your condition. If there is a delay in authorisation, query this with your medical aid.

Most importantly, discuss your financial concerns with your treatment team so that they can help guide you where possible to maximise your benefits and if possible, find ways to save you costs. Make sure that you are aware of costs beforehand so that you’re not caught unaware. Ask where possible, if payment plans are available when there are additional unavoidable costs.

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