Cancer Treatment and Your Medical Aid
Year in and year out medical aid members tend to over-look their scheme’s emails or printed documents. These letters ask them to review their current plan and medical aid cover and amend as necessary. And with the risk of cancer being so high and the cancer treatment so very costly, both medical aid members and cancer patients cannot afford to be smug about the medical aid plan they choose.
Cancer treatment – The window period
In December of each year, medical aids offer a window period. This means members can upgrade their plans. And once that window closes members are not able to review their plans until the following December. That, in turn, means that upgrading in order to receive better cover for treatment, such as cancer, causes delays.
When choosing medical aid plans it is important to consider exactly what the plan will cover as well as considering additional costs such as treatment for breast cancer and how much cover is afforded.
Understanding the terms
Members should understand terms like “exclusions” and “biological therapies”.
It has become an all too regular occurrence where cancer patients discover that their medical aids won’t pay for their cancer treatment and organizations such as Campaigning for Cancer has realized the importance on educating and equipping medical aid members with the knowledge and decisions regarding cancer cover.
Although the many different schemes in the country offer a variety of options, a good oncology benefit ought to consist of an overall annual limit of around R300 000 per beneficiary.
Members must carefully consider benefits that claim to offer “unlimited cover”. Often these have excluded treatments. Sometimes schemes will exclude some of the newer innovative treatments which tend to be more expensive than standard chemotherapy. And that’s even though the treatments have Medicines Control Council approval.
Cancer treatment – Lower benefits
Certain medical aid schemes offer lower benefits of between R90 000 – R150 000 cancer cover per family which means that members may only be provided with cancer treatment in line with PMBs and those are pretty much equivalent to the type of treatment a member would receive in a government hospital.
Sometimes members have trouble getting their medical scheme to cover the recommended treatment plan and oncology medications.
Numerous schemes tend to exclude newer medicines and as a result members have to pay out of their own pockets. The newer medicines don’t as yet have generic alternatives and can cost anywhere between R100 000 to R500 000.
Understand the scheme rules
Members must make sure that they are clear with their scheme’s rules when it comes to consultation fees for oncologists. They should check whether their scheme limits the number of specialist visits or what the consultation limits are.
Members should find out whether oncologists make their scheme’s decisions regarding treatment. Or do they use professionals who may not have the required oncology know-how?
So when schemes allow members to upgrade or downgrade at the end of a year, members should assess their cancer benefits and ensure that they are adequately covered.