Most medical aid hospital plans include chronic cover which ensures that you can access medicines and some medical services for the treatment and management of your chronic condition. This is is an essential cover as most chronic conditions have serious and even life-threatening complications if it is not managed properly.
It is important to understand how the chronic cover works on medical aid and the way in which it takes care of you in the long run. Second to the hospital cover on medical aid, chronic care can be extremely expensive and often unaffordable in the private health sector without proper chronic cover. While hospital cash back plans also cover hospitalisation for chronic diseases, these insurance policies do not pay for the medication for chronic conditions.
What is chronic cover?
To understand what chronic cover does for you with a medical aid hospital plan you need to first understand what a chronic condition means. A chronic condition is any illness or disease that lasts for a prolonged period of time and often for the rest of your life. Common chronic diseases include high blood pressure (hypertension), hypercholesterolaemia (high blood cholesterol), diabetes mellitus (sugar diabetes) and osteoarthritis. There are hundreds of other chronic diseases. These conditions need to be managed over the long term because it is usually incurable and does not resolve on its own within a few weeks or months. But long term management is not always affordable.
Even a medical aid hospital plan only includes chronic cover with the hospital benefit. Depending on the type of medical aid hospital plan that you have, your chronic cover will pay for the consultation, tests and medication for the treatment and management of the chronic disease. Since the disease is ongoing, treatment and monitoring is also ongoing. Which means the cost is ongoing. Chronic cover spares your day-to-day (out-of-hospital) medical aid cover which can be quickly exhausted if it had to cover the management of chronic diseases. It also spares you from having to take the money out of your pocket to pay for your chronic care or go to a public hospital for treatment.
Limits for the Year
As with any benefit on medical aid, there are limits for chronic cover. These limits are applied to the individual or family depending on the number of people covered under the hospital plan. In the past, a person may run out of chronic cover before the end of the year and then have to pay for the chronic medication out of their own pocket. Fortunately new regulations means that a medical aid is committed to pay for care for certain ailments throughout the year, irrespective of the chronic limit. This is known as the prescribed minimum benefits (PMBs) and includes 26 conditions that can be life-threatening if ongoing care is not available. All other chronic conditions are therefore subject to the annual limit.
Medication
Chronic conditions usually have to be managed through the use of medication. Approved drugs will be paid for from the chronic cover and these days most medical aids will pay 100% for certain generics but should you wish to use the ethical (branded drug) or other generics that are not approved, then you will be liable for a co-payment. Not all diseases are considered to be a chronic condition and therefore ongoing medication cannot be paid from the chronic cover in every case.
Tests
A range of diagnostic tests may be needed as part of the management of certain disease. For example, diabetics needs to monitor their blood glucose levels on a regular basis and the chronic cover may therefore pay for glucose meter test strips or sticks. This is dependent on each individual plan. Patients may be required to go to certain approved clinics or centers for regular monitoring and medication dispensing as part of the chronic cover but this varies from one plan to another.
Chronic Disease Waiting Period
If you have a pre-existing chronic disease then you cannot access the chronic cover for the first 12 months of your membership. There is no immediate cover for pre-existing medical conditions on any hospital plan if you have just started up on medical aid.This is a standard rule applied by all medical aids, irrespective of whether you have full comprehensive cover or just a hospital plan. Once the 12 month waiting period passes, you can then access the full chronic benefit. Medical aids require that you fill out a questionnaire at the time of joining the scheme to fully declare you current chronic diseases. Patients who fail to mention a pre-existing condition can be held liable for any payments made by the medical aid upon them discovering the situation.
References :
Prescribed minimum benefits. Board of Health Care Funders