The Council for Medical Schemes (CMS), regulator of the medical schemes industry, advises medical scheme members to use their benefits wisely – especially at the beginning of the year – with the aim of making their benefits last longer.
Acting Chief Executive and Registrar of the CMS, Daniel Lehutjo, says now that members have chosen to either stay on the same benefit option or move to another one, they should resist the urge to spend all their benefits in the first couple of months to avoid running out of cover when it may be needed the most, later in the year.
“We appeal to members to also use their medical scheme benefits wisely and spread the use of it evenly during the year. Make use of your general practitioner (GP) to coordinate your care and discuss any healthcare needs and concerns for the year – the CMS latest annual report shows schemes that paid more benefits to GPs paid less benefits to hospitals, indicating care coordinated by GPs decreases the chance of members being hospitalised.”
The most common advice is to not use your benefits to buy sunglasses, multivitamins or other lifestyle items over the counter, but instead use it for essential medicines when the need arises. Members are also advised to ask their doctors to prescribe in formulary drugs (list of drugs that will be funded by medical schemes for each condition).
A formulary regularly consist of generic medication, especially in higher schedule categories, which is generally cheaper and thereby save funds while it is just as effective as the more expensive alternative.
“We encourage people to make use of the preventative screenings and tests many schemes offer. Members should also seek to register on the relevant chronic management programmes if they have certain illnesses, thereby ensuring their condition is monitored and that they receive all the necessary care,” explained Lehutjo.
Should an emergency arise, or any of the 270 medical and certain chronic conditions occur, medical scheme members can rest assured that they are covered through prescribed minimum benefits (PMBs). Schemes have to pay for PMBs in full from the risk pool according to the Medical Schemes Act 131 of 1998, except where a member voluntarily uses a non-Designated Service Provider (DSP).
There is also a false believe that schemes only pay for PMBs and do not fund other non-PMB conditions. An analysis of selected schemes in the CMS Annual Report shows PMBs constituted 52.5% of the R102.2 billion paid for all risk benefits, meaning 47.5% of this amount was paid for other conditions.
However, members need to know the rules of their schemes and what benefits are included in their specific benefit option to know which non-PMB conditions are included in their option.
There are medical interventions available over and above those prescribed for PMB conditions but schemes may choose not to pay for them.
The following advice will greatly assist members to determine if and how much they are likely to pay out of their own pockets:
- Contact your medical scheme and ask who the DSP is for the service or product that you need.
- If you need to undergo an operation, ask your surgeon for the codes that will be charged. This will include the procedure codes and those for any other products that is needed, such as an internal prosthesis that will be used.
- Discuss the medical scheme tariff with your surgeon and negotiate the price that you will pay.
- Contact your medical scheme and ask whether the specific type of product will be funded in full. If not, make sure that you know what part of the cost will be for your own pocket.
- Ask your scheme to provide you with a list of DSPs for the product or procedure you need to undergo. The scheme may appoint a surgeon, hospital and anaesthetists as designated service providers. These providers usually have agreements with the schemes for non-PMBs as well.
- Where possible, ask the provider to assist you with obtaining codes from several companies. It should be noted that your doctor may have preferences based on your clinical condition. In this instance you as a member will not have sufficient evidence to shop around for better quotations.
- Determine if there is a shortfall and make plans how this will be funded.
- Obtain pre-authorisation for procedures as provided for in the rules of your medical scheme.