How South African medical aids work

As diabetics, we need to understand the details of our medical aids. What we are due, what we can fight for, and how to motivate that fight. We’ve put together an easy-to-understand guide to how South African medical aids work to help you do just that.

Understanding medical aids

Diabetics often ask for more than we get from our medical aids. While it may seem like anyone with diabetes is fighting an ‘us vs them’ battle against their medical aid, that’s not really the case. As a member of a medical aid, you pay a monthly premium to belong to that fund. These premiums are pooled together to treat all the members. And as such, you get a say in how the money is used. Of course, this is a limited say, as there are thousands of members and everyone’s vote counts – but your vote does count. 

Medical aids are also called medical schemes – here’s a detailed report of how they work. In essence, though, all South African medical aids are non-profit organisations, registered with the Council for Medical Schemes and run by a board of trustees. They are all subject to the Medical Schemes Act.

Yes, all medical aids are non-profit. (That’s a surprise to many!) The rrustees are elected at the annual general meeting (AGM) through a nomination and voting process, by the members of the scheme. The trustees elect a chairman (principal officer) and appoint the administrator. The administrator administers the medical fund – they are independent from the medical fund, and are allowed to make a profit. They receive instructions from the fund and have to manage the risks and benefits on behalf of the fund. The administrator is also accredited annually by the Council of Medical Schemes, through various auditing processes.

“Schemes exist for their members as all funds are pooled and safeguarded, to be used to pay claims in accordance with the scheme’s rules, and ensure that all members are equitably and fairly cared for (relative to their choice of benefit plan).”

Discovery Health

 At the AGM, special concerns or motions that were raised and added to the agenda will be discussed by the members of the board. If you are concerned about the diabetes benefits, you can access the medical aid’s website and ask for the motion to be added to the agenda, and raised directly to the board. (Because of COVID-19, most medical aids have postponed their AGMs for a few months.)

What are Prescribed Minimum Benefits (PMBs)?

One of the most important things for people with diabetes to understand about their medical aid is their list of Prescribed Minimum Benefits (PMBs). Every Type 1 and Type 2 diabetic gets a list of PMBs they are allowed each year, free of charge, regardless of which plan you’re on. The treatment plan must be in line with the minimum standard of care offered by the state sector. If you are on the lowest membership tier (‘hospital plan’), you are entitled to at least what patients get in state as a standard of care. Additional benefits are added as you upgrade and buy up to a better benefit option. PMBs don’t only cover diabetes, they apply to the 27 chronic conditions on the Chronic Disease List (CDL).  Here’s a detailed explanation of PMBs.

The benefits and treatment formularies are different for Type 1 and Type 2 diabetes. Ask your medical aid to send you the treatment plan for your type of diabetes.

PMBs for diabetes may include:

• Monthly medication as prescribed by your doctor 
• Monthly testing equipment
• Visits to an endocrinologist (diabetes specialist)
• An annual visit to a dietician
• A visit to a podiatrist (once a year)
• An annual eye check with an ophthalmologist (eye specialist)
• Certain blood tests like the HbA1c

Top tip: Once you’ve asked your medical aid for your list of PMBs, look at the ICD10 codes next to each item carefully. You may be allowed a visit to a dietician, but only for 30 minutes (for example), and you want to make sure that the codes on the list that you are allowed match the codes the dietician uses on their invoice. You can tell the dietician which codes you see on the list when you make your appointment. 

How to motivate for more:

You might have done your research and discovered something you think will be better for you and your diabetes: a better way for you to manage your condition. If you’re in better control, your risk for long-term diabetes complications is less, so you’ll end up costing your medical aid less.

But what do you do if what you want isn’t on the list of PMBs and isn’t covered by your benefits? Perhaps you don’t think that 100 or 150 strips a month is enough, and you want to motivate for 200 strips a month. Perhaps you want to motivate for a CGM or you want to use a new or different brand of insulin. You might want to motivate for an insulin pump. Medical aids have a list called a formulary which is where they list what is available to all members on their scheme, depending on your diagnosis (Type 1 or Type 2). It has a list of approved medication and brands. 

Different insulin:

If you want a different brand of insulin that’s not on the formulary, for example, you may be able to use the rand value of the insulin that has been approved towards the insulin you want (the capped amount). This could result in a co-pay, if the one you want is more expensive.

More testing strips:

Extra strips can only be motivated for through your doctor. They will have to write a letter of motivation to the medical aid why you need to test more: because you are pregnant, for example, or because you have been struggling with too many hypos or hypers.

CGM:

If your medical aid rejects your request for a flash glucose monitor or CGM, you can complain to the CMS. Here’s exactly how to do that.

Remember that some technologies or drugs, although more costly than your current treatment, will allow you to better manage your condition. This will ultimately reduce the cost for your medical aid. This is why it’s worth applying for what you believe would be best for you.

Insulin pump:

The first step to getting an insulin pump covered by your medical aid is to speak to your doctor. They will start the process of motivating for it if you are a suitable candidate… They generally need a good reason for motivation: age, pregnancy, brittle control etc. Most motivations are a step-by-step process and you need to keep on top of them, and keep trying. Persistence is key!

Tip: As a member of the medical aid, you always have the right to question, escalate or appeal a decision. The administrator should be transparent and provide you with specific reasons for their decisions. If the answer is that it is not part of the medical aid policy, you can request a copy of the policy.

Diabetes advocacy

The current #cgm4all campaign is working towards getting CGMs on the medical aid formulary for next year. Find out all about it – and get involved! – here. One of the ways we can ensure our voices are heard is by joining together. SA Diabetes Advocacy is a group of all the diabetes patient organisations in South Africa. We are all working together to make the voice of those with diabetes louder. 

It is so important for people with diabetes to understand their medical aid, and what they’re due. Remember that you can also call your medical aid and ask questions, at any stage. If you don’t understand the answers, keep asking until it is explained to you. You have the right to be empowered to make the best possible decisions for your health.

Photo by Kelly Sikkema on Unsplash

ADC-24218 V1 Jun 2020