Sarah Bullen
Nerves of steel are no longer mandatory to fill in a medical aid application form if you are suffering from a chronic condition. Those polite questions inquiring about the state of your health can no longer serve as embedded red flags that will ensure your application lands neatly in the trash pile.
The new legislation dictates that applicants with chronic or high-risk conditions cannot be refused access to a medical aid scheme nor can they be charged higher premiums.
Once through the door, coverage for chronic medical conditions – one that lasts longer than three months and requires ongoing treatment – still varies from scheme to scheme.
Fedsure’s Aid for Aids offers members two choices of policies worth R25 000 or R45 000 a year. Discovery Health provides a R20 000 per annum limit for treatment in a private hospital. In terms of medication it allows members to manage their own medical savings account.
Discovery has also introduced a “top-up” hospital and chronic medication benefit plan that members can buy separately from the medical aid policy. Sold as an insurance product, the “top-up” plan offers members a further R15 000 per annum coverage – but it can also exclude high- risk members, as the insurance industry is not covered by the new Act.
But the department of health is determined to stop Discovery marketing its new range of “top-up” products, arguing that it allows discrimination against the old and the sick.
Discovery is one of the new generation medical schemes that have a “managed aid” component for chronic conditions. The new industry buzzword, managed aid, will allow the member and his doctor to work with a medical aid on how best to manage healthcare for the condition.
There is also a growing move to allow members to manage their own medical savings account. The scheme will allow you to choose whether you want to spend your monthly benefits on a pair of prescription Gucci sunglasses or AZT. It can also, if you can find a doctor to diagnose it as a chronic medical condition, include impotence, hair loss or insomnia – opening up the world of lifestyle drugs such as Viagra, Propecia and Sonata.
The cost of anti-retroviral drugs ranges from R600 to R2 200 a month, while Viagra costs around R80 a pop.
The key shift in managed aid is the awareness that it is in the interests of the medical aids to keep their members healthy. Medscheme’s Gary Taylor explains that keeping members healthy essentially means they remain at work, paying their medical aid contributions and staying out of hospital.
These schemes also guarantee confidentiality between medical aid and member, so there is no chance of your employer finding out if you are HIV- positive, a diabetic or impotent.
Medical schemes are permitted, however, to evoke a 12-month waiting period for members joining with a pre-existing condition.
The Act also includes a lengthy set of minimum conditions that medical aids are obliged to provide to all members from the day they sign on. Vital to people with chronic conditions is the obligation for a medical aid to cover all treatment in a public hospital. This means that there is still available treatment for opportunistic illnesses in the 12-month wait before full benefits kick in.
Ditched from the minimum benefits section of the final Act was a stipulation that cover for HIV-positive members ends when their CD count drops below 100. Cover for HIV is now comprehensive and complete.