The Chronic Conditions or Chronic Disease List (CDL) specifies medication and treatment for the 25 chronic conditions that are covered in this section of 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 ensure appropriate standards of healthcare, so-called treatment algorithms were developed for the CDL conditions. The algorithms, which have been published in the Government Gazette, can be regarded 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
If you have one of the 25 listed chronic conditions (diseases), your medical scheme not only has to cover the medication, but also 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.
Doctors do not usually have a direct contractual relationship with medical schemes. They merely submit their accounts and if the medical scheme does not pay, for whatever reason, the doctor turns to the beneficiary for the amount due. This does not mean that PMBs are not important to healthcare providers nor that they don’t have a role to play in its successful functioning.
- Doctors should familiarise themselves with ICD-10 codes and how they correspond with PMB codes. If you use the correct ICD-10 code your account will definitely be paid as PMBs enjoy 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 proper clinical records of patients so that when a formulary drug or protocol is not effective, or causes adverse side-effects, you can justify your alternative recommendation.
- 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.
- Allow your practice to be listed as a DSP.
- The “payment in full” concept is there to ensure accessibility of healthcare services for medical scheme beneficiaries if the DSP is not available; it is not a reimbursement model.
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