This is part 2 of a four-part series on you and your medical scheme. Click here for part 1.
Choosing a medical scheme that requires you to use networks of general practitioners (GPs), specialists, optometrists, pathologists or pharmacists doesn’t mean you will receive poor-quality treatment.
A good medical scheme should ensure that it contracts with practitioners who provide quality care, and that its members’ claims will be paid in full.
Networks are one of the main ways in which schemes are protecting themselves against the rising costs of health care. Managed-care protocols are another measure that schemes use to control costs (see How managed care affects your treatment). If schemes did not contain the costs of treatment, they would have to hike your contributions significantly and/or slash your benefits.
“There’s a misconception among some members that network healthcare providers are sub-par and are on medical schemes’ networks only because they cannot find enough patients or business of their own,” Jeremy Yatt, the principal officer of one of the country’s largest open medical schemes, Fedhealth, says. “This is certainly not true. Contrary to popular belief, network providers help us to offer quality health care, and provide schemes with the data and supporting evidence to ensure that they adhere to best practice.”
He says one of the results of schemes entering into agreements with doctors or other healthcare practitioners is that members who belong to options with medical savings accounts are certain of the tariff they will be charged. This helps them to stretch the funds in their savings accounts.
“A good, symbiotic relationship with service providers is high on our priority list.
“We realise all too well how essential healthcare service providers are to members receiving the full scope of healthcare services, but, on the other hand, doctors would not be able to practise without medical schemes paying the members’ claims, because most people cannot afford to pay for healthcare services out of their own pockets,” Yatt says.
Schemes set up networks for different reasons, and you need to know whether you must use a network for your scheme to pay your claim, or to avoid a co-payment. You should also know when, although it is optional to use a network, it would be in your interest to do so, because your claim will be paid in full or the funds in your medical savings account will last longer.
Here are the types of networks that your medical scheme may use:
Designated service provider for the PMBs
A scheme may appoint a designated service provider (DSP) that you must use to be covered for a prescribed minimum benefit (PMB).
The PMBs cover all medical emergencies, a list of conditions that are life-threatening or that can seriously affect your quality of life if left untreated and 25 common chronic conditions.
A DSP is a provider or a group of providers chosen by the scheme as its preferred provider or providers for the diagnosis, treatment and care of a PMB condition.
If a scheme has appointed a DSP and members use a non-DSP for a PMB service, the scheme may impose a co-payment or deductible. The co-payment or deductible must be defined in the scheme’s rules, and the co-payment cannot be 100 percent of the cost of the service.
A co-payment of up to 25 percent of the cost of the service, or equal to the difference between what it would have cost the scheme had the member used the DSP and the actual cost of the service, is considered by the Council for Medical Schemes (CMS) to be fair.
However, if you obtain a PMB service from a non-DSP involuntarily, a scheme may not impose a co-payment or deductible. Regulations under the Medical Schemes Act state that a PMB service is obtained involuntarily when:
• The service was not available from the DSP or was not available without unreasonable delay;
• The member or his or her dependants required immediate treatment, or it was not reasonable to expect the beneficiary to travel to the DSP in order to be treated; or
• There was no DSP in reasonable proximity of the beneficiary’s place of business or residence.
The terms “unreasonable delay” or “reasonable proximity” are not defined in the regulations.
Designated provider for non-PMBs
Schemes typically offer cheaper contributions on options that use provider networks. On these options, if you do not use the specified healthcare providers, you will face a co-payment, or your treatment will not be covered at all.
Typically, a scheme will contract with a hospital group, a network of GPs or a primary healthcare network, such as CareCross.
Schemes may also offer certain benefits, such as oncology or dentistry, through a network.
On most of Fedhealth’s options, members who visit a doctor who is part of the scheme’s GP network will have their consultation paid for by the scheme, rather than from their medical savings account.
Preferred providers
A scheme may set up a network of preferred healthcare providers. Although, unlike a DSP, members do not have to use a preferred provider, if they do, they will be charged preferential rates and/or in the case of benefits paid for by the scheme, they will enjoy full cover.
Schemes often set up preferred provider networks of specialists. These specialists agree to charge at the scheme’s rate, so they are assured that the scheme will cover your bill in full. (If a specialist charges more than the scheme’s rate, the scheme pays you, the member, its rate, and you need to pay over that amount, as well as the balance, to the specialist.)
The incentive for specialists to agree to charge at the scheme’s rate is that the scheme, in turn, agrees to pay them directly, which reduces specialists’ risk of bad debt. Some members do not reimburse specialists with the money their scheme has paid them for a claim.
Other preferred provider networks may be set up with, for example, a group of optometrists, with whom the scheme has negotiated a preferential rate.
Discounted options
Efficiency-discounted options (EDOs) are offered as variations on the existing options. Some schemes offer members the choice of more than one EDO on a particular option. EDOs are designed around members’ willingness to limit their choice of provider. A healthy person, for example, might agree to use the public healthcare sector for chronic care, because he or she is unlikely to use this benefit.
Members of EDOs agree to pay lower contributions in return for having their choice of hospitals and doctors restricted when they are treated for all medical procedures, not just the PMBs.
In addition, the scheme may demand a co-payment for certain elective procedures.
Schemes must obtain permission from the CMS to launch EDOs, because, technically, EDOs violate the Medical Schemes Act. The Act states that members who belong to the same option must pay the same contributions. The only grounds for charging a different contribution is the number of dependants a member registers on the scheme, or if a member is a low-income earner.
Paresh Prema, the general manager: benefits management at the CMS, says most EDOs save costs by contracting with selected hospitals, but some also negotiate discounts with GPs, chronic-care service providers, medicine courier services and dispensaries. Most schemes manage to negotiate discounts of between 15 and 30 percent, he says.
Capitation options
When a scheme sets up a capitated option it enters into an arrangement with one or more healthcare providers in terms of which it agrees to pay the provider a pre-negotiated fixed fee per member in return for the provider supplying its members with certain medical services.
The set fee remains the same regardless of how many times you see the doctor, dentist or other healthcare provider contracted to service you.
Most capitated options have networks for day-to-day benefits and control the costs of hospital benefits through hospital networks or monetary limits on benefits.
Yatt says Fedhealth’s BlueDoor capitated option offers unlimited visits to a GP through its GP network, and set benefits for optometry and dentistry from optometrists and dentists in its network. For example, you get basic single vision or bifocal lenses and R182 for a frame every two years.
BlueDoor members can only use hospitals in the Fedhealth network.
Members are entitled to two visits a year to a specialist, but often only if they are referred by a network GP.
ADVICE FOR MEMBERS
• If your medical scheme option requires you to use a designated service provider (DSP), or doctors or hospitals that belong to a network, and you don’t like the providers chosen on your behalf, you can upgrade your option. Most schemes allow you to downgrade your option at any time, but, in most cases, you are permitted to upgrade your option only at the end of the year.
• You can complain to the Council for Medical Schemes (CMS) if your scheme’s DSP is a long way from your home or place of work. The CMS may ask your scheme to add a provider that is more convenient for you.
• If your scheme changes its DSPs in the middle of the year, you can complain to the CMS, because it is a material change to the terms of the contract between you and your scheme, particularly if the change adversely affects your ability to access healthcare services. The CMS can order the scheme to ensure that you are not denied access to health care.
• If a surgeon recommends that you or a family member undergo an elective procedure, ask your medical scheme how much of the cost it will cover before you ask for pre-authorisation. You can use the information to negotiate with the surgeon over his or her fee. In most cases, surgeons are prepared to be flexible over the fee if it is certain what the scheme will pay.