Your medical aid scheme’s cancer cover may not buy you the particular treatment or cancer care that you need.
A decent cancer benefit will consist of an overall annual limit of about R300k to R400k per beneficiary. Be aware of benefits that promise “Unlimited Cover” – this is hardly the case and often the scheme rules will exclude a lot of cutting edge and expensive treatments, which may be prescribed for you based on your particular health needs.
Read the fine print! Some cheaper benefit options only offer between R90k to R150k cancer cover per family! With this you and your family will only be provided treatment in line with prescribed minimum benefits (PMBs), which are the same as you would have received at a government hospital.
One scheme offers cancer cover of R400k on its higher options and R200k on its lower options. Once members reach their limit they are entitled to unlimited benefits – subject to a co-payment of 20%.
The cost of cancer drugs is often the main problem faced when asking medical schemes to cover treatment plans recommended by doctors.
Many scheme rules specifically exclude newer cancer medicines (often referred to as specialised medicines or biologics) requiring you to pay for them out of your own pocket and can cost between R100k to R500k per course! As these new medicines may represent an essential part of your cancer treatment it is vital that your benefits allow for these costs and do not prohibit you from accessing them.
Cancer and PMBs
Not every cancer is classified as PMB. Cancer will be categorised a PMB if it has not spread to another organ, if survival is expected to be 5 years or more, or if the prescribed treatment has shown survival benefits for patients.
A PMB cancer does not entitle you to unlimited treatment. Scheme policies, rules and protocols must still be taken into account.
Upgrading Your Cover
Medical aid members are allowed to change benefit options (to higher or lower plans) at least once per calendar year and usually toward the end of the year in order to become effective 1 January of the following year. As the cut-off dates vary per scheme per year please enquire with your scheme directly.
You can join or change medical schemes anytime of the year but members may be underwritten and face waiting periods depending on the reason for moving etc.
The final cut-off dates are usually during December but you need to contact your medical scheme during October or early November so that you can speak to an adviser and make an informed decision about which plan to change to.
Last year’s cut-off dates of some of the bigger schemes were as follows:
Downgrade your plan – anytime.
Upgrade your plan – the cut off date last year was 9 December
Downgrade your plan – before 15 December (last year)
Upgrades can be done anytime but new benefits are applied pro rata for the year.
Downgrades by 9 December (last year)
Downgrades and upgrades needed to be done by 31 December.
Adapted from a www.campaign4cancer.co.za article.