Cancer is one of the leading causes of death in South Africa and may become even more prevalent – medical journal, Lancet, predicts a 78 percent spike in cancer cases by 2030.
Despite the prevalence of the disease and the high price tag associated with cancer treatment, medical aid schemes in South Africa do not automatically cover all treatment costs.
Comprehensive medical aid options that provide cover both in and out of hospital usually have unlimited oncology benefits or limited but with a good overall amount. However, this doesn’t necessarily mean that all expenses will be paid for in full.
Instead, medical aid schemes pay providers at scheme rate, or in some cases 200 or 300 percent of the scheme rate. This rate may be a lot lower than the one healthcare providers actually charge, in which case members have to cover the remaining costs when designated providers are not used.
More affordable medical aid options offer limited oncology cover. Once the limit has been reached, any additional payments have to be taken upon by the member (in most cases). Furthermore, schemes have the right not to cover the costs resulting from non-PMB cancers where it has been stated.
If a cancer is considered a PMB condition (Prescribed Minimum Benefits – defined conditions and treatments which must be provided, by law, to all medical aid scheme members and beneficiaries in full and without co-payment, regardless of the benefit option selected), a medical aid scheme is legally obliged to continue paying for treatment at cost, even if the oncology benefit limit has been reached.
In order to limit PMB expenditure, medical aid schemes can insist that beneficiaries consult specialists and use hospitals in their networks. Low-cost medical aid options may limit members to treatment at state facilities only. In addition, each medical aid scheme covers only medicines listed on a scheme formulary (an official list giving details of prescribable medicines). Entry-level plans typically cover the cost only of generic alternatives, rather than of more expensive branded medicines.
When is cancer considered treatable?
According to the Medical Schemes Act, cancer is considered treatable when:
- only the organ of origin is affected and there is no spread of the disease to contiguous organs, or
- the organ of origin and other life supporting organs and systems have not been irreparably damaged by the cancer
Before you subscribe to a particular medical aid scheme or plan, it’s a good idea to investigate the cover it offers for cancer treatment. Among the issues you should consider are:
- the monetary value of the oncology benefit per beneficiary per year
- what specialised treatments or biologics, if any, are covered by the benefit structure
- whether cover for oncologist and specialist consultations is limited
- the scheme’s cancer treatment protocols
- whether the scheme permits plan upgrades at any time during the year.
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