Breaking down your oncology benefits

Being diagnosed with breast cancer is terrifying. Suddenly there seem to be a million decisions that need to be made. Everything feels like its spinning out of control and you don’t know where to start.

One of the best places to start is with your medical aid. Knowing what your benefits are, how they are structured and how they will influence your treatment will help you feel in control again.

Breaking down your benefits

Rand values

Oncology benefits are normally given a monetary value per family for the year. They often have a sub-value set aside for other treatments, for example: radiology; pathology and biological drugs. It is imperative that you read the benefits carefully and if you don’t understand, you need to ask your medical aid’s oncology department.

The benefits can be difficult to understand and this leads to confusion and misinformation.

Below are three examples of how plans can differ:

a) “R450 000 oncology benefit with a R200 000 sub-benefit for biologicals. Enhanced ICON protocol”

This would mean that you have R450 000 oncology cover for all chemotherapy, radiation and consultations. Of that R450 000 there is R200 000 that can be used for biological drugs such as Herceptin. It also tells you that your designated service provider is ICON and the protocol available to the oncologist is Enhanced protocol.

b) “R150 000 oncology benefit for Prescribed Minimum Benefits (PMBs) conditions only”. This would mean that there is R150 000 worth of oncology benefits. There are no sub benefits for biologicals and the cancer has to be a PMB.

c) “R200 000 for chemotherapy

ICON STD”. This means that there is R200 000 for all medication and the facility fees and radiation fees must come from your overall annual limit.

As you can see the way the benefits are worded can be quite confusing. So read them carefully, make notes and then phone your medical aid with any questions you might have.

Designated Service Providers

There are two main Oncology Designated Service Providers (DSPs). Most oncologists in South Africa belong to both SAOC (South African Oncology Consortium) and ICON (Independent Clinical Oncology Network). In both cases the review committees are oncology specialists in their respective fields.

 

 

 

Some things to remember

While you are going to a DSP oncologist, remember to confirm what your DSP hospital is. Most medical aids will require you to be admitted for all referred treatment to a DSP hospital even though your oncologist is not at a DSP hospital. If there are any chemo related admissions the co-payments can be waivered by the medical aid as the DSP oncologist is admitting you. However, if you are referred to another specialist (surgeon, etc.) it is best to have the oncologist refer you to someone based at your medical aid’s DSP hospital. Not going to a DSP (oncologist or hospital) can have financial implications of up to 40% of the total costs and can translate to hundreds of thousands of rands.

PMBs 

PMBs entitle you to many benefits regardless of what scheme or option you are on. This includes tests, x-rays, consultations and medication required to remain healthy. However, it does not allow an “open door” policy where any and all tests and treatments (such as PET scans and biological drugs) are covered in full from PMB. In 2004 new

legislation and regulations stated that all schemes needed to cover 207 specified conditions. You can find these on the Council of Medical Schemes website (www.medicalschemes.com).

These conditions would be covered by the scheme regardless of exclusions and benefit limits, as long as the treatment is available in a state facility. This was put in place to help the schemes stay financially viable and to help members receive treatment for the listed serious and chronic conditions without running out of benefits. However, it doesn’t mean that your accounts get paid by the scheme in all circumstances. It means that once your oncology benefits are depleted then your treatment can continue within the specified State Protocol.

Cancer, as a primary diagnosis, is classified as a PMB, but not all related treatment is classified as PMB. PMB treatment is defined as being freely available and routinely used in a state facility. It is, however, no longer a PMB once the cancer has spread to distant organs and the chances of surviving five years are less than 10%. This would affect your medical aid cover if you are on a hospital plan and only have cover for PMB conditions and oncology benefits.

By using these oncology-funding guidelines you will be able to ask your medical aid all the relevant questions to ensure you get the best possible treatment available to you, with the least amount of stress.

Remember, your medical aid has a team of clinical staff available to help you. They will be able to give you all the information you need and answer all your questions about how and what is covered. It is their job to be there to assist you with benefit queries and to guide you with what is covered.

While you are going to a DSP oncologist, remember to confirm what your DSP hospital is. Most medical aids will require you to be admitted for all referred treatment to a DSP hospital even though your oncologist is not at a DSP hospital. If there are any chemo related admissions the co-payments can be waivered by the medical aid as the DSP oncologist is admitting you. However, if you are referred to another specialist (surgeon, etc.) it is best to have the oncologist refer you to someone based at your medical aid’s DSP hospital. Not going to a DSP (oncologist or hospital) can have financial implications of up to 40% of the total costs and can translate to hundreds of thousands of rands.

By using these oncology-funding guidelines you will be able to ask your medical aid all the relevant questions to ensure you get the best possible treatment available to you, with the least amount of stress.

Remember, your medical aid has a team of clinical staff available to help you. They will be able to give you all the information you need and answer all your questions about how and what is covered. It is their job to be there to assist you with benefit queries and to guide you with what is covered.

There are a few things to confirm with your medical aid when it comes to PMB’s:

Will the follow-ups come from oncology, or PMB once treatment is finished?

Some medical aids will only apply the PMB benefit once all the day-to-day benefits are depleted, while others apply PMB benefit from the moment they have confirmation that the condition is a PMB and for as long as it remains a PMB.

Which DSP’s should be used?

Written by Gillian Warren

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