Know Your Sight Rights
Johannesburg, South Africa – December 2017 : Adequate eye care throughout your life is particularly important, considering the various age related eye conditions that exist and the importance role that eyesight plays in a healthy life.
If you are over 40, or have eye health problems, you should choose a medical aid scheme that has adequate provision for eye care.1pg1a But with more than 80 medical schemes in South Africa, how do you make sure that the cover you choose will cover your eyesight?
“Most medical aids and options cover eye conditions and special examinations, with a few requiring specialist referrals and authorisation for consultation, provided that sufficient funds are available,” says Dr Yolandie Coetzee from Envision Centre for Sight. “Patients between the ages 30 and 60 should ensure that they have cover for trauma, glaucoma, eye diseases related to diabetes and eye infections. There are other less common eye diseases, such as keratoconus (a condition in which the clear tissue on the cornea bulges outward), where the treatment can be quite expensive. After the age of 60, patients should also ensure they have cover for cataract surgery and macular degeneration.”
The thorny issue of refractive surgery
Coetzee says most medical aid options – excluding hospital plans – provide cover for eye treatment and procedures as long as sufficient benefits and funds are available. In addition, most hospital plans cover eye surgery.
She advises that patients need to be aware, however, that refractive surgery – to correct conditions such as near-sightedness (myopia), far-sightedness (hyperopia), astigmatism or presbyopia (difficulty in focusing on close objects and small print) – is considered lifestyle surgery and medical aid schemes differ significantly on whether they will provide eyesight cover, and how much. Many medical aids will allow patients to use their savings or optical benefits on their plan, but very few will cover the entire cost of the surgery. It is the patient’s responsibility to get approval from their medical aid and to ascertain what percentage of the cost will be covered.
Good eyesight plays a pivotal role in your wellbeing and is a significant factor in safety, retaining independence, and maintaining a good quality of life as we get older, however when refractive errors are left uncorrected or when the correction is inadequate, they can cause severe visual impairment and even blindness. In fact, according to the World Health Organisation (WHO), refractive error of the eyesight is one of the most common causes of visual impairment globally.2pg1a+b In South Africa, uncorrected refractive error was one of the three most debilitating sense organ diseases in 2013.3pg2a The annual years of healthy life lost per 100,000 people from uncorrected refractive error in this country has increased by 6,5% since 1990, an average of 0,3% a year.3pg1b
Finding the best fit for your needs
Dr Rajesh Patel, head of benefits and risk at The Board of Healthcare Funders of Southern Africa (BHF), advises patients to make sure that the benefits of the scheme they opt for are a good match for the health needs that they and their family experience, or are likely to experience, to the best of their knowledge. this includes eyesight issues.
“Never assume that the benefits under a new scheme may be the same as your current medical aid,” he adds. “For example, optical benefits on some medical aids allow for a new pair of prescription glasses every year, while others only provide this benefit every second year. You may want to chat to your medical aid broker for more detailed advice.”
It’s important to check the benefit limits and ensure that these are fit for your needs and that of your family, throughout your changing lifecycle. “This can be a complex process and it’s a role best undertaken with the help and advice of a professional healthcare broker who will do a needs analysis with you and based on that, make recommendations on the best scheme and benefit for your needs and budget,” Patel says.
Common eyecare procedures and services
- Cataract surgery is the most common eye care procedure and it is routinely covered by at medical aid tariffs.
- Glaucoma, a condition which is prevalent in South Africa, causes blindness if left untreated, making glaucoma screening important.
- Annual screening of diabetics for diabetic eye disease may also include expensive special eye examinations.
- Interpatient variability in the treatment of macular degeneration, which includes intra-vitreal injections, makes funding of these procedures unpredictable.
“There are many less common eye diseases, and patients must ensure that they ask the right questions,” says Dr Coetzee. “Although it is not always possible to obtain authorisation for the latest and most ideal treatment for a condition, there is usually an alternative option that will be covered by the medical scheme. We advise patients to confirm coverage prior to treatment because if funds are depleted, the patient will be liable. It’s important to consider the risks and benefits of all available treatment options, ask the right questions and keep an eye on your available funds and benefits so that you are not taken by surprise.”
Understanding medical aid eye care benefits
Consultations and special tests for eye care are generally funded from day-to-day benefits. Prescribed Minimum Benefits (PMBs) are a set of pre-defined conditions that all medical schemes in South Africa have to cover, by law. Patel points out that the existence of PMB means that anyone who is part a beneficiary of a medical scheme, no matter what plan they’re on, can receive treatment for PMB listed eye conditions and that the cost of these will be covered. PMBs also covers emergency eye treatment.
“Many schemes have designated service providers / preferred provider networks, so always check which hospitals and doctors you’re allowed to use under the scheme’s rules before you join, and whether they are in your area and easily accessible” cautions Patel. “If your current optometrist or ophthalmologist is not a member of your scheme’s provider network, you may have to change doctors, to avoid possible co-payments.”
Check what the day-to-day limits are and how much your Medical Savings Account (MSA) is per year.
- Remember that some private hospitals and doctors do not charge medical scheme rates, so it’s important to check before you get landed with an enormous bill after surgery.
- Consult an independent broker. They will be able to advise you and help you choose the scheme or plan that will be most beneficial to you.
- Ask about the waiting period and any condition that you may be excluded from.
- Find out about eyesight exclusions before you sign anything.
For more information on the eye conditions covered under PMBs, please visit http://medicalaidbible.co.za/list-pmb-conditions-prescribed-treatment/
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- The South African Medical Journal. [Internet]. South Africa’s cataract surgery rates – why are we not meeting our targets? [cited 2017 Sep 14]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21920119
- Health24. [Internet]. Dry eyes; [cited 2017 Sep 14]. Available from: http://www.health24.com/Medical/Eye/Eye-disorders/Dry-eyes-20120721
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