The Chronic Disease List (CDL) defines the medication and treatment medical schemes must cover for the 25 chronic conditions included in the PMBs.
Chronic renal disease, Addison’s disease, Asthma, Bronchiectasis, Cardiac failure, Cardiomyopathy, Chronic obstructive pulmonary disorder, Coronary artery disease, Crohn’s disease, Diabetes insipidus, Diabetes mellitus types 1 & 2, Dysrhythmias, Epilepsy, Bipolar Mood Disorder, Hypothyroidism, Hypertension, Glaucoma, Haemophilia, Ulcerative colitis, Systemic lupus erythematosus, Schizophrenia, Rheumatoid arthritis, Parkinson’s disease, Hyperlipidaemia, Multiple sclerosis.
To manage risk and maintain appropriate healthcare standards, the Department of Health developed treatment algorithms for CDL conditions. These algorithms, published in the Government Gazette, serve as benchmarks or minimum standards for treatment. This means that the treatment your medical scheme MUST provide for, may not be inferior to the algorithms.
How is the cover for Chronic Conditions
Do you have one of the 25 listed chronic conditions (diseases) ? Your medical scheme must cover the medication. In addition, it should cover doctors’ consultations and tests related to your chronic condition. The scheme may make use of protocols, formularies (lists of specified medicines), and Designated Service Providers (DSPs) to manage this benefit for Chronic Conditions.
HealthCare Providers Responsibilities
Doctors do not usually have a direct contractual relationship with medical schemes. Doctors often simply submit their accounts. If the medical scheme doesn’t pay for any reason, they turn to the beneficiary for the outstanding amount. However, this does not mean that PMBs are unimportant to healthcare providers. Nor does it imply that they have no role to play in the successful functioning of the healthcare system.
- Doctors should familiarise themselves with ICD-10 codes and how they correspond with PMB codes. Using the correct ICD-10 code ensures your account gets paid, as PMBs qualify for guaranteed medical aid cover.
- Consider on which option your patients are and what can realistically be covered before recommending a drug or treatment.
- Alert patients to the fact that their condition is a PMB and encourage them to engage their medical scheme on the matter.
- Keep detailed clinical records for each patient so you can justify an alternative treatment if a formulary drug or protocol proves ineffective or causes side effects.
- Do not abuse PMBs. The result will be an unsustainable private healthcare system with unaffordable contribution increases. Abuse could compel government to consider alternative payment options in the private healthcare sector.
- Register your practice as a Designated Service Provider (DSP).
- Medical schemes use the ‘payment in full’ concept to ensure beneficiaries can access healthcare services when a DSP is unavailable; they do not use it as a reimbursement model.
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