Understanding Chronic Medicine, Designated Service Providers & Preventative Care Benefits

Welcome to the MedXpert podcast hosted by Optivest Health Services. I’m your host Lincoln. In this episode, we bring you expert knowledge from professionals in the healthcare industry to offer insights and knowledge on how you can maximise the value from your medical scheme. Now, I’m joined by two individuals from different medical schemes.

Ellen Gray, a health channel manager from Momentum Medical Scheme and Adele Wade, a senior consultant in distribution services at Bonitas Medical Aid. Welcome to you both, ladies.
Thank you, Lincoln. Thanks for having us.

Well, the purpose of today’s discussion is to gain insight and to understand why medical schemes are compelled to cover the chronic disease conditions, like diabetes or high blood pressure, and the importance of Designated Service Providers also known as DSPs as well as preventative care benefits.

Now, let’s start with one example of a medical scheme’s purpose. It is to provide chronic medication besides this being a regulatory requirement. Now, Adele if I can start with you, how will I know if I should join a medical scheme? If I’m an existing member, will my chronic condition be covered by my medical scheme?

Thanks Lincoln, very important question. You know, medical schemes are governed by the Medical Schemes Act and there is a part in the Medical Schemes Act that is referred to as PMBs or Prescribed Minimum Benefits. Part of the PMBs is the chronic medication section. So, all schemes must cover a predetermined list of 27 chronic conditions. So, you must then, as a member, look at that list to see if your chronic condition is on one of those or if it isn’t one of the chronic conditions that’s covered on that list.

All options should cover the 27 predetermined chronic conditions. You also then have certain other chronic conditions that might not be on the 27 predetermined list and mostly your more comprehensive plans would cover those conditions. So, if you do use medication every day, here I mean life sustaining medication that you use every day, check whether it is on the predetermined list or whether you need to go onto a more comprehensive option, that covers more than the 27 chronic disease lists. That’s basically how you would check as a member.

Now, Ellen if I can move on to you, let’s use the example: If I’m a medical scheme member and my chronic condition has been registered by my medical scheme, how do I prevent out of pocket payments on my chronic medication?

Thank you, Lincoln. So, as you said, maybe to reiterate the registration is very important. So, we do have members, they fill in the application form and they mention the chronic conditions and then think there is an automatic registration, but the registration is an active process, if I can say it like that. So, you need to contact your medical scheme and register your chronic condition and the medication, which is usually done either with a form that your doctor must complete or with a call.

Once that is done, what’s important to prevent out of pocket expenses is to opt for medication that may be on the formulary. So, it’s a list of medications that are covered in full. Sometimes that’s not possible. So, you would have a medication that may carry a co-payment, but that will all be confirmed upon registration. So that’s why it’s also so important to make an informed decision when you register. The next important point is to use your Designated Service Provider that is chosen based on your option.

So, depending on which plan you opted for, you may have a provider where you have to get your medication from. There may even be a doctor that you should be using to get your script, but that’s all determined by your medication and that’s where Optivest would come in very handy as a financial advisor to just guide you through the jungle of choices. But formula is important as well as the DSP from where you get your medication to avoid out of pocket expenses.
I think members must understand, like you said, it is an active process. So, there is some sort of obligation on their part to make sure that they are registered and obviously they follow the formulas as well then.

Alright, Adele coming back to you, how does the use of a DSP benefit medical scheme members and how will I be encouraged to make use of a DSP? So, Lincoln DSPs, just referred to that and reiterate again, are your Designated Service Providers that have several benefits to members. You know, the DSPs are healthcare providers that are very carefully selected by schemes. So those are their specific partners that they contract to make sure that members have agreed upon rates and ensure that those members get the adequate quality of care as well.

So, your first reason or benefit that you have by contracting, or going to see a Designated Service Provider, is cost saving. Schemes make sure that members receive the treatment, and they receive that treatment at a reduced cost with lower or no out-of-pocket expenses. So, I think that’s your very first advantage of using DSPs. Secondly, I’ve mentioned the quality of care or quality assurance. So medical aids get in contact with the DSPs, and they make sure that they’ve got very stringent quality standards. The DSPs also undergo performance evaluations so that we make sure that our members get the quality care. So that’s your second reason, a benefit to a member when using the DSPs offered by the scheme. And then lastly the claims process, if you submit your claim through a Designated Service Provider, usually that process is simpler and faster and it just reduces the administration burden at the end of the day, both for the provider as well as the member. If I can summarise those three advantages of using a Designated Service Provider.

Alright, that brings me to the next question then. Many people say that perhaps DSPs aren’t the same quality of care. So, I guess the question then is to ask you, do lower costs of health cover provided by DSPs mean lower quality of care? And if I’m in a network option, why is it important that I understand my chosen option?

Well, so Lincoln like Adele already said, the opposite is true. DSPs are monitored very closely; they are vetted on an ongoing basis. There’s also performance management, which makes sure that these chosen DSPs adhere to the standards and highest quality that the scheme would obviously like to have for their members. So, as I said, if anything, you get a higher level of care from a DSP because they work so closely with the schemes and really have the best the member’s best interests at heart.

What’s important to understand in your option is if there is a DSP you need to use then you really must do so because otherwise you may end up with out-of-pocket expenses. But what is nice is that they are very familiar with the formula in other words the codes that are covered. So, it’s almost like your benefits will last much longer if you choose a DSP because they are very familiar with what the scheme will cover in full. There is also reference pricing applied, they often charge within the medical scheme rates. So, you really are almost safer in the hands of a DSP because they align their services with your scheme’s benefits. When it comes to preventative screening benefits, there are nice benefits offered by medical schemes. Ellen, what are preventative screening benefits?

These are benefits that are offered by the scheme to encourage early detection and preventative care. So, the old motto of “prevention is better than cure”. We would like members to actively take charge of their health and go for annual check-ups. So usually these differ based on your age and gender, and sometimes also underlying conditions where we then prompt members to please go for these checkups. But you would start off with a health assessment once a year where we, for example, test your cholesterol, blood sugar, height, weight, and blood pressure. Then there are regular screenings offered that depend on specific target groups like for women, we would offer mammograms and pap smears because the earlier you detect any abnormalities, the better the chances of a cure.

We have prostate checks which are blood tests, and we have everything from child immunisations to maternity programs to make sure our ladies go for their scans, et cetera. So, they’re there to encourage members to take charge of their health and not only go to a doctor when you’re sick, but to annually go and do certain check-ups that give a good idea of your overall health.

If I could maybe just ask Ellen, how does one access these benefits? Are there any registration requirements? If you were to use an example of a benefit, are there some benefits that you would need authorisation for?

A very good question, Lincoln. So, it differs from scheme to scheme. On the Momentum side, we would like members to do pre-authorisation for these benefits. It’s just to also encourage them to actively seek that treatment. But it really depends on scheme to scheme. And again, very important I think is to check in with your financial advisor, depending on which scheme you’re with. What are the rules around these? Because what’s also important is that sometimes you need to use a DSP or specific doctors to utilise those preventative screenings. Sometimes you can use whoever you like, but it’s limited to a certain Rand amount or to the medical aid rate. 

So it’s quite important to also educate yourself around those benefits and make sure that you know which rules to follow in order to get the benefit needed.

Adele, I guess this also ties in with what we’re speaking about now, but where I can access my preventative screening benefits from?

So as Ellen mentioned, most schemes offer these preventative care benefits and the nice thing about that is, it won’t affect your savings or your day-to-day benefits that are available. So, you’ll have automatic access to them. Do that wellness screening. A lot of the schemes have access, or members have access to an app on their phones where they can do certain screenings checks. So that’s one way that they can access those.

But for some of the members that would like to go and consult with a doctor or a nurse at a clinic, that’s how they can access the wellness screening benefits. And then again, depending on scheme to scheme, whether they’ve got rules in place to use certain DSPs for instance to go to for your mammogram or your pap smear, et cetera. But mostly, I agree with Ellen, follow the rules of the scheme, make use of the DSPs, and make sure that if authorisation needs to be obtained by your scheme that you follow those rules to be able to have access to these preventative care benefits.

I think that’s also important like you were saying, just obviously follow the rules of the scheme. If you want to get full access to benefits and essentially what this does is it gives you access to additional benefits offered by your medical schemes.

I think all that’s left to say today, ladies, thank you for your taking the time to come out and chat to us today. I think it’s very insightful for everyone to know about this. There are not many platforms where you can have these kinds of deep conversations to speak about these topics. So, it’s useful.

For more information on these topics, you can head over to our website at www.medxpert™.co.za where we have free resources available to assist you with more information.

Ladies, thank you so much for joining us today and we hope to see you in future. Thank you for having us.