List of Chronic Conditions Covered by Prescribed Minimum Benefits
September 9, 2016
For decades people have searched for a cure for chronic conditions such as cancer, depression, diabetes, arthritis and stroke. It is astounding how many people in the 21st century have diseases. But lifestyle choices, the foods we eat and our genes all play a part in us getting illnesses.
There are quite a few conditions that are chronic. And patients need to change their lifestyle of self-care and also endure demanding treatments for chronic diseases. Many patients with chronic medical problems also suffer from depression. Therefore cognitive therapy may be appropriate for patients with chronic sickness.
Perhaps you’re wondering if your medical scheme plan includes your chronic condition. Well, there some benefits apply to all members. Hospital plans and medical aids are legally required to provide Prescribed Minimum Benefits or PMBs.
Medical Schemes Must Cover for Diagnosis and Treatment of Chronic Illnesses
There is a list of conditions that qualify for Prescribed Minimum Benefits as delivered by medical schemes. Interestingly, the list of PMBs includes 25 chronic diseases. This list is called the Chronic Disease List (CDL). Regulations state that medical schemes can’t use the member’s medical savings account to pay for PMBs.
In fact, the South African government prescribes 25 different conditions that medical schemes have to include in the medical plans they offer their members. Significantly, the medical aids must cover these PMBs.
The Medical Schemes Act 131 of 1998 and its Regulations stipulate that medical schemes must also include life-threatening emergencies, 270 defined diagnoses and 27 chronic conditions. And just some of these chronic diseases include –
- Bipolar Mood Disorder
- Cardiac Failure
- Chronic Renal Disease
- Multiple Sclerosis
- Parkinson’s Disease
- Rheumatoid Arthritis
- Ulcerative Colitis
The Prescribed Minimum Benefit legislation covers these sicknesses on all benefit options as defined. These particular diseases are life threatening, and treatment will improve the quality of life for the member. Remember, it is important to register your chronic conditions so that your scheme pays for the services and your day to day benefits aren’t affected.
Diagnostics for Chronic Conditions
Medical schemes must provide cover for these illnesses, but the medical aid won’t pay for diagnostic tests where you don’t have a PMB condition. Guidelines for the right treatments for these CDL chronic sicknesses appear in the Government Gazette.
The 25 chronic diseases on the list are the most common, life-threatening diseases. doctors are supposed to understand the guidelines so that they can help medical aid members get the treatment they need for these conditions.
If you and your doctor opt for other treatment, you might have to part with a co-payment towards the cost of that particular medicine. But your medical aid will still have to pay for the treatment if your doctor can prove that the standard medication won’t be safe for your condition.
Sometimes the medicines on the list will be generics, which are very effective. However, if you want the ‘real thing’, that doesn’t appear on the list, your medical scheme might only foot part of the bill and you will have to pay the rest.
Do what your Medical Scheme Says
So do research and understand how chronic illnesses and treatments work. Remember that if you don’t abide by the rules, you’ll simply face having to pay some or even all of the treatment cost.
All info was correct at time of publishing