Know your medical benefits, avoid costly co-payments
Medical Scheme premiums increased by CPI + 5% in January for most medical schemes. These increases are a result of an ageing, sicker population using more services, and not by medical schemes affording doctors excessive tariff increases. As a medical scheme member, being aware of your rights as far as Prescribed Minimum Benefits (PMBs) go, could save you a lot of out-of-pocket healthcare expenses in the coming year.
“Lack of knowledge of PMBs ends up costing scheme members unnecessarily out of pocket for essential medical attention. And worse still, some members find themselves exhausting their savings on treatment or care that should have been accessed as PMBs.
These PMBs may not be paid from savings, according to the Medical Schemes Act” says Dr Johann Serfontein, CEO of the Ophthalmology Management Group (OMG), which manages private practice issues on behalf of the Ophthalmological Society of South Africa (OSSA).
PMBs, as defined by law, are the minimum level of diagnosis, treatment and care costs your medical scheme must cover in full. Many of us have probably found ourselves in situations where, although we have medical aid, paying what healthcare professionals call a co-payment. This is because medical scheme tariff increase for doctors since 2006 have historically not reflected increases in the costs of running practices and also because schemes have designated service provider networks (DSPs). These DSPs are doctors and hospitals that your medical scheme chooses as their preferred provider when you need treatment or care. In situations where you opt for a non-DSP, you often have to pay a portion of the bill, which is the co-payment.
“One of the big concerns in eye care is that DSP networks often do not consider the number of sub specialist fields in ophthalmology. An ophthalmologist with a special interest in glaucoma is not necessarily the right person to see for a complex Retinal detachment, for instance. Scheme DSPs do not differentiate between such sub-specialities. Sometimes schemes appoint facilities as DSPs, who do not have the required equipment for ophthalmic surgery. Patients then face an uphill battle to get co-payments waived. It is important to remember that emergencies such as Retinal detachments, which require same-day surgery, are almost always PMBs”
“All in all, PMBs exist for the benefit of medical aid members as a way to ensure that they get access to certain minimum health services regardless of the plan option they are on. These benefits may not be less than the services provided in the public sector. The Council for Medical Schemes (CMS) considers availability of a service in 3 public facilities in 2 provinces as PMB level of care. There are 270 serious health conditions that fall under PMBs as well as all emergency conditions, and 25 chronic diseases.”
Serfontein says that when it comes to health services related to eye care, the PMB Regulations make provision for a number of eye diseases which require the attention of specialists such as ophthalmologists to diagnose and treat.
According to the Act, one of the reasons for PMBs is to alleviate pressure from the public sector by avoiding unfunded utilisation when benefits run out. It surprises Dr Serfontein that the CMS allows certain Medical Schemes to name the State as their DSP, as even if the scheme is billed (which happens infrequently), the money does not go back to the facility where the resources are consumed, effectively causing unfunded utilisation. Such funds go back into the common state funding pot, removing such resources from availability to public sector patients who cannot afford medical schemes.
Some of the most common eye care PMBs include Cataracts, Age-Related Macular Degeneration (AMD), treatable cancer of the eye and orbit, corneal ulcers, superficial injury of the eye, glaucoma, and Retinal Detachments. However, many other eye related ailments are covered under PMBs, as these would leave the patient blind if left untreated.
“Not enough people are aware of their PMB benefits in the eye care space. Our continuous labour is to put an end to avoidable blindness. We are learning that this mission is also going to have to be coupled with some education on what rights patients have in both public and private sectors. Matters such as PMBs are a classic example. Medical aid members find themselves paying exorbitant amounts over and above their medical aid instalments for services that should have legally been funded for them by the scheme. Brokers fulfil a vital role in this education. If we are to accomplish any of the gains we have envisioned in the eye care space nationally, it definitely starts with equipping patients with information,” Serfontein concludes.