“Will my medical aid cover my treatment?” is a question we hear incredibly often at Crossroads , and generally, the answer is yes, with a few exceptions. This blog will go into the if, why and how your medical aid or hospital plan can assist you in getting treatment.
What are PMB’s ?
Prescribed Minimum Benefits are features of The Medical Schemes Act that ensures every member has access to basic health care services. A medical aid legally has to cover these to the bare minimum, if they want to be registered with the Council for Medical Schemes. They apply regardless of what the scheme is, which means that even hospital plans have these benefits included.
In the case of rehabilitation, the focus from a doctor’s point has to be diagnostic, this means that the duration or cause of the illness does not determine the validity of treatment. This also means that rehabilitation for illegal drugs is not any different from treatment for legal ones, such as over the counter medications or alcohol.
How much do they cover ?
The rules set forth by the Council of Medical Schemes dictate that rehabilitation should be covered for up to 3 weeks. Some medical aids also make detoxification benefits available when combined with rehabilitation. The monetary value of these benefits does vary from scheme to scheme, with some paying out more than others. This does not impact on the ability to use these benefits but is rather associated with how much the co-payment will work out to.
Under what circumstances will your medical aid not pay ?
There are a few things that will exclude you from using these benefits, which are listed below:
If you are on a waiting period: Generally, when you join a medical aid for the first-time, certain benefits are excluded from the scheme. This is so that people don’t take advantage of the medical aid – join on one day, use the benefits and then cancel the next day. This all varies from scheme to scheme and differs for individuals. Speak to your broker or call the customer care line for clarity.
If there are exclusions on your medical aid: Some medical aids offer budget options. This may limit your options for treatment to certain hospitals and doctors. This may apply to rehabilitation centres as well. Though we do see this from time to time, what we see more often is “medical insurers” who do not need to conform to the same rules as medical aids when it comes to prescribed minimum benefits.
If you have used your benefits: Medical aids limit the benefits associated with certain conditions. Should there be no more benefits remaining on the medical aid they will not authorise another stay in treatment. These benefits reset each calendar year. This means that if you have used your benefits in 2020, they will be available to use again on the 1st of January, 2021.
If you do not stay for the full duration of treatment: As a rule, medical aids pay out per day, so if you stay in treatment for half the time, they will only cover half the fees. Again this varies between schemes and options. A medical aid may refuse to pay entirely if treatment is not completed. This is one of the many reasons it is recommended that you stay in treatment for the full amount of time.
Some general advice regarding medical aid and treatment
First and foremost, the best advice when it comes to medical aids is to be honest. We have seen many people denied benefits because they did not declare their addiction or alcoholism as a pre-existing condition. This is especially true if you have been in treatment before, but also applies if you have ever spoken to a doctor or received advice from a doctor regarding your addiction. This is especially important when first joining a medical aid, as it will have an impact on waiting periods and therefore the benefits available to you. It may seem awkward but keep in mind- everything that happens between yourself and a medical aid or broker is confidential.
On the subject of confidentiality, what is claimed from your medical aid is privileged information. This information will not be passed on to anyone else who is not associated with the treatment team or the medical aid. Many people are concerned that this information will be common knowledge or easily accessible – it is not. The only exception is that the information may be accessible to other members on the medical aid plan.
How do I know what my medical aid will cover?
The easiest way to determine availability or value of funds is to do a pre-authorisation. This can be done prior to admission. This is obligation free, if pre-authorisation is obtained and the person is never admitted, the benefits will still be available to use at any point in the future.
Contact us to find out more about how your medical aid can assist you in getting treatment, we work with most approved medical aids.
