Year in and year out medical aid members tend to over-look their scheme’s emails or printed documents that 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.
The window period
In December of each year, medical aids offer a window period whereby members can upgrade their plans and once that window closes members are not able to review their plans until the following December which means that upgrading in order to receive better cover for treatment such as lung cancer and breast cancer will have to be put on hold.
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
Terms like “exclusions” and “biological therapies” also need to be understood.
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 do need to carefully consider benefits that claim to offer “unlimited cover” as often there are treatments not included. Sometimes schemes will exclude some of the newer innovative treatments which tend to be more expensive than standard chemotherapy even though the treatments have been approved by the Medicines Control Council.
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.
One of the main issues members tend to face is trying to get their medical scheme to cover the treatment plan and oncology medications as recommended by their doctor.
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 and check whether their scheme limits the number of specialist visits or how much is allocated for the consultations.
Members should find out whether their scheme’s decisions regarding treatment are made by oncologists or 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.