IBD and your medical aid

One of the most challenging aspects of IBD care in South Africa is understanding and negotiating the complex medical aid industry. Below is a glossary of the common medical aid terms and how they apply to IBD.

Act 131 of 1998, better known as the Medical Schemes Act, came into effect on 1 February, 1999. All South African Medical Schemes are legally obligated to adhere to the Act and comply with all regulations passed by the Government Gazette.

Acute Condition
An acute condition is a disabling condition, such as tonsillitis or appendicitis, which heals entirely after treatment.

Benefits are the medical services, procedures and/or medication that you are covered for in return for your monthly medical aid contributions. The benefits you receive are dependent on the particular medical aid plan you’ve chosen. Some medical aid options (plans) offer comprehensive benefits (both-day-today and in-hospital cover), while others offer only in-hospital benefits. Interestingly regulations state that money accumulated from higher costing comprehensive plans cannot be used to cross subsidise care for patients on lower plans. 

Challenging a medical aid decision concerning my IBD care.
Unfortunately medical aids may have little knowledge or understanding about IBD care and approval for medication, admission to hospital or to undergo a procedure may be declined. To challenge this decision you can ask your doctor to speak to the medical doctor advising the scheme and often the approval will be granted. If a medical scheme steadfastly refuses to approve a treatment which is available and required for your IBD then you can approach the Council of Medical Schemes to challenge the decision.  www.medicalschemes.com

Chronic Disease List (CDL)
The Chronic Disease List, or CDL, is an official list of 25 conditions and diseases that medical aid schemes may not exclude. In other words, medical schemes have to offer healthcare cover for these 25 conditions. Both Crohn’s disease and Ulcerative colitis are included on this list.

Chronic Condition 
A chronic condition is any condition which demands ongoing treatment, or treatment for a period of at least three months. Examples are IBD, High Blood Pressure and Diabetes.

Chronic Medication
Chronic medication is the medicine that someone with a chronic condition (see definition) needs. A medical aid scheme has the right to limit its expenditure in terms of Prescribed Minimum Benefits (see definition) by controlling which medicines and treatment options are covered in terms of its schemes. Members might have to stick to a certain brand, or choose generic medicines, for example. However a medical scheme may not, according to the Healthcare Act, restrict treatment unless this is scientifically indicated.  

Examples of IBD chronic medication include:

  • 5-Aminosalicylate tablets (Asacol, Pentasa, Salazapyrine, Mezvant, Salofalk)
  • 5-Aminosalicylate suppositories (Asacol, Pentasa)
  • Azathioprine (Azapress, Azamun)
  • 6-Mercaptopurine (Purinethol)
  • Methotrexate (Abitrexate)
  • Adalimumab (Humira)
  • Infliximab (Revellex)
  • Golimumab (Simponi)

Condition-specific waiting period
A condition-specific waiting period may be imposed on new medical aid members who have an existing medical condition, such as IBD, when joining the scheme. During this waiting period, which may range from 3 months to one year, these members are not allowed to claim for any costs associated with the condition. Once this period has passed, the condition will be covered according to the benefits offered by the member’s chosen plan. Joining a medical aid with a known diagnosis of IBD will result in a waiting period before claims for IBD will be covered. It is therefore very important to be sure of your waiting period before switching medical aids as you may be without IBD cover for up to a year. However if you are forced to change medical aids when starting a new job, to join the company preferred scheme,  this waiting period MUST be waived and benefits for IBD should start immediately. 

A consultation refers to any time you visit a medical practitioner, such as a doctor, dentist, gynaecologist, specialist, etc. Every practitioner charges a different set of rates for their consultations.

A co-payment is a certain percentage of the cost of a medical procedure or its treatment for which the member is held liable. A penalty co-payment is sometimes also charged where members voluntarily use a non-designated service provider (DSP) or opts to use medicine(s) which is not on the schemes formulary list.

Current Procedural Terminology (CPT) Code or “Procedure Code”
CPT codes are used to describe tests, surgeries and any other medical procedure performed by a healthcare provider on a patient. As you might imagine, this code set is extremely large, and includes the codes for thousands upon thousands of medical procedures. In IBD a common CPT code is 1653 used to denote a colonoscopy procedure.

A dependant is any individual who belongs to a principle member’s medical aid plan, and whose medical aid fees are covered by the principle member. For example, if a principle member adds their children to their medical aid plan, their children are the dependants on that plan. Individuals who qualify as dependants are spouses, life partners, children (including step-children, adopted children and foster children), siblings or parents of the main member.

Designated Service Provider (DSP)
A doctor or hospital selected by the scheme as the preferred provider to provide healthcare services to its members in terms of the diagnosis, treatment and care, in respect of one or more prescribed minimum benefit conditions. This can be a major problem for IBD patients where a DSP e.g a hospital does not have a gastroenterologist or the DSP doctor is not trained to treat IBD. 

Ex-gratia Application
Ex Gratia means “as a favour”. It is a discretionary consideration by your medical aid (based on a funds resources) which is only made when an Ex-gratia Committee believes that an exceptional situation exists which warrants funding. It is not a benefit that the medical aid has to offer, nor is funding guaranteed. Ex Gratia awards may be made by the Ex-gratia Committee provided it is satisfied that significant financial hardship or exceptional medical circumstances exist. Many IBD patients use the Ex-gratia process to access expensive IBD medication such as biological therapy (adalimumab, infliximab, golimumab) until they are able to upgrade their medical aid to a plan which covers such medication. Smaller funds may not have the financial resources to offer ex-gratia funding. 

Elective surgery
Elective surgery refers to any surgery that is non-urgent and not associated with a life threatening condition.

Exclusions are medical conditions which a medical aid scheme is legally permitted to exclude from its health insurance offering. Examples are self-inflicted injuries and cosmetic surgery. Exclusions may also include recently introduced expensive treatments. 

Hospital Plan
Unlike a comprehensive plan, which offers both day-to-day and hospital cover, a hospital plan offers only in-hospital benefits. Hospital plans cover the major cost of hospitalisation and as such are best suited to members who are healthy, do not often visit doctors, and who simply wish to have major medical benefits in place in the event of an emergency or unforeseen hospitalisation. A hospital plan is not suitable for most IBD patients who require regular out-of-hospital tests, treatments and consultations. 

ICD-10 Codes
By law, every claim that is submitted to a medical aid scheme must include an ICD-10 code. The ICD-10 code system is based on a medical diagnosis of a global catalogue of diseases, and it was developed by the World Health Organisation in order to standardise the diagnostic process. It is critical that IBD is coded correctly on all your statements, laboratory requests forms and x-ray / scan request forms. Your medical aid will then identify that the claims are for a chronic / PMB condition and you are more likely to have your costs covered or be reimbursed if you have already made a payment. 

ICD10 codes for Crohn’s disease all start with K50

  • K50.0 Crohn disease of small intestine
  • K50.1 Crohn disease of large intestine
  • K50.8 Other Crohn disease
  • K50.9 Crohn disease, unspecified

ICD10 codes for Ulcerative colitis all start with K51

  • K51.0 Ulcerative (chronic) pancolitis
  • K51.2 Ulcerative (chronic) proctitis
  • K51.3 Ulcerative (chronic) rectosigmoiditis
  • K51.4 Inflammatory polyps
  • K51.5 Left sided colitis
  • K51.8 Other ulcerative colitis
  • K51.9 Ulcerative colitis, unspecified

Late Joiner Penalty
According to the Medical Schemes Act (see definition), South African medical aid schemes may impose a late joiner penalty for people older than 35, who want to join the scheme. In order to minimise risk, this penalty is calculated in terms of how long the person has not belonged to a registered medical aid scheme – the longer without medical aid, the higher the imposed penalty.

Medical Savings Account (MSA) 
A medical savings account (MSA) is where a member’s own money is kept aside to pay for day-to-day medical expenses.

National Pharmaceutical Pricing Index (NAPPI) codes are used to provide information about pharmaceutical and surgical products. This includes details about the manufacturer, registration, strength and dosage. All IBD medications are NAPPI coded.

National Health Reference Price List (NHRPL)
The NHRPL is a national pricing system regulated by the Department of Health and the Council for Medical Schemes. Basically, the NHRPL stipulates the rates to which medical aid schemes must adhere in terms of benefit payments. However, medical service providers are not bound by this rate and some thus may charge significantly higher rates. In such cases, members are liable for the difference between the provider’s rate and the NHRPL rate. IBD is a chronic condition requiring regular treatment. Always discuss the rates your doctor will charge to manage your IBD as this may be more than your medical aid will pay. 

Members of medical aid schemes are required to notify and obtain authorisation from their schemes before going into hospital if they are to receive non-life threatening or non-essential hospital treatment or undergo diagnostic tests. 

A pre-authorisation will require:

  • Date of admission or procedure
  • The hospital or clinic practice number e.g Heavenly Bodies Clinic   Practice Number: 1234
  • The doctors practice number e.g Dr T. Smart Practice number: 4321
  • The CPT code or Procedure Code.  e.g 1653 Colonoscopy
  •  The disease ICD10 code e.g K51.9 Ulcerative colitis

Pre-existing Condition
A pre-existing condition refers to a condition that a prospective member has been diagnosed with, and where treatment has been advised by a medical practitioner, within one year prior to his or her membership application.

Prescribed Minimum Benefits (PMBs)
By law, all medical aid schemes are obligated to provide medical cover for these conditions (IBD included), as set out in the Regulations of the Medical Schemes Act which states

“PMB conditions are governed by regulations as stipulated by the Medical Schemes Act 131 of 1998 and amendments, concerning fees payable for Prescribed Minimum Benefits and Chronic Disease List of 1st January 2004, specifically Chapter 3, Paragraph 8, sections 1 and 2. It states that any benefit offered by a Medical Scheme must reimburse in full, without co-payment or the use of deductibles, the diagnostic treatment and care cost of prescribed minimum benefit conditions as specified in Annexure A”. 

The rationale of the PMB legislation was to prevent patients losing their medical cover in the event of serious or chronic illness and thus burdening the already stretched state healthcare services. Unfortunately this piece of legislation has been abused by healthcare providers (charging exorbitant fees for PMB conditions as the medical aid is by law obliged to pay for care regardless) and by medical aid funders who decline treatment for PMB conditions when by law they are obliged to cover the cost of care. 

Waiting Periods 
Waiting periods are imposed when a new member joins a medical aid scheme. It could either be a 3-month period during which no claims will be processed, or a 12-month period if the applicant suffers from a pre-existing condition (note that the applicant will be covered for everything except his or her pre-existing condition during this period). It is very important when joining a new medical scheme that you notify them of any pre-existing condition such as IBD. If it is discovered that you have withheld your history of IBD your medical aid membership will be terminated and you will not be able to easily join another scheme.