Hello fellow Lymphies! 

Today we are interviewing a special guest, Michelle Hey from Approach Administration, who helps a growing client base navigate their medical aid schemes. Michelle has been in this industry for over 30 years and has a wealth of information that we will share with you. 

While we always keep our fellow Lymphies at the forefront of our minds when creating blogs, this interview will be helpful to anyone with questions regarding medical aid schemes in South Africa. 

Vivory Team:
The next question is, why do some medical aids not pay for compression garments needed for those living with lymphoedema? Our garments at LympheDames are Nappi coded to allow for them to be claimed from medical funds, they are medical garments but why is it that some medical aids wouldn't be paying for these garments?

Michelle:
It depends on the plan that you're on. If you're going to be on an entry level plan, such as a hospital plan, you're not going to get access to these kinds of devices or additional benefits that you may require. It’s up to you to weigh up the pros and cons of various plans, whether you’re on an existing plan or looking at taking out a new plan. 

The question to ask is: what are your needs? A lot of the time people may say they only require hospital cover, and that’s great when we are healthy but what happens when the tables turn and your health takes a turn? 

You may find that all of a sudden, you are living with a new condition that requires additional care. So do your costings, for example if you find that on your current plan, that costs R1881.00 per month, includes coverage for your treatment but the next tier up, which is going to cost R4000.00 per month, includes you claiming your medical device which costs R 2600.00 once off every 6-12 months, then stick with the plan that covers your treatment and purchase your additionals out of your own pocket, saving yourself some money in the long run. 

Again, it all depends on your needs and the cost of the medical devices you need for your condition, always take your unique factors into consideration when making a decision about your plan.

Vivory Team: 
Great, Ashley and I have had this conversation before about how you cannot put a price on your health, we have an article Buy Yourself a Sleeve, Get a Pair of Big Girl Panties Free: Prioritizing Health Over Luxury where we do cost comparisons against the cost of a compression sleeve vs a few niceties.

Vivory Team:
I can understand why trying to make sense of your plan can be so overwhelming, it’s a lot for anyone to fully understand.

Michelle:
Absolutely, I’ve been in this industry for 30 years and I still need to do my homework as it’s forever changing. To answer the last part of the question, PMBs do not vary from company to company. 

You can head over to the CMS Website to access that list and see if your condition is covered by PMBs. 

Where your treatment for PMBs varies within your plan, for example: you are on a hospital plan and are diagnosed with depression. You can apply to your medical aid to have your psychologist and/or Psychiatrist visits funded from the PMB benefit. They normally approve 12 - 15 out of hospital visits from the PMB benefit but medication won't be covered. But say you were on a medical aid plan on a higher level tier, you could have additional sessions plus your required medication covered.

When clients enquire about medical aid my first question to them is to find out whether their plan needs to be based on affordability or need. You may come to me with a more serious condition, such as ankylosing spondylitis which is an inflammatory disease that, over time, can cause some of the spinal vertebrae to fuse and the cost for treatment amounts to over R7000.00 a month. Now the cost of this treatment could be beyond the most executive level plan that you could get. Or you could have high cholesterol and mild asthma where your medication costs R 300.00 a month, then an entry level plan would be sufficient.

The higher your medical aid plan, the more chronic conditions are covered. My advice is to do proper research about the plan you’re thinking of going on and make sure that it covers your needs.

Vivory Team:
Going back to needs and affordability, What is the shortfall of taking out a medical aid with a pre existing condition? How does it affect your premium? Does it only affect your premium for maybe the first three months, or three to six months of taking out a new medical aid plan? Or would the cost of a late join be baked into the long term cost of your plan?

Michelle:
Let’s use the following scenario; a good few years ago if you had diabetes, were 65 years old and a smoker, you would be outright declined on your application to join a medical aid. That changed somewhere between 2000 & 2003. Now the only recourse your medical aid can impose on you is a 3 month general waiting period. You will still pay the premium quoted to you but you will not be able to use your medical aid during that waiting period except in the event of an accident where you would require emergency care. 

In some cases depending on the terms of your acceptance to the medical aid you will be allowed to make use of your medical aid for Prescribed Minimum Benefits only during the 3 month waiting period.

If a client comes to me with a pre-existing condition, such as lymphoedema, they would automatically be given a 12 month waiting period before they could make any claim for the pre-existing condition however should something happen such as their appendix burst or they require a heart bypass then cover would be in place for that as it is unrelated to the pre-existing condition. 

Should you sign up for your medical aid plan and 2 months into it be diagnosed with a new condition, you would be covered for that. 

Vivory Team:
And there's no point in trying to hide the fact that you've got a pre existing condition, because once you make your claim especially so early into joining a plan, it is going to get looked into right?

Michelle: 
Correct. Do not ever not disclose a condition.

Rather disclose your pre-existing condition and take the knock for the waiting period. In some cases depending on whether you have been on a medical aid before, how long ago you were on a medical aid or if you jump from one medical aid company to another you may find that your condition could be excluded by the company however if your condition is one of the conditions listed under PMB then it has to be covered. 

Taking out cover is not always cut and dry. Each person's history and current health condition is unique, this is where I would look into the terms given to them on their application and navigate from there. 

When it comes to hospital procedures, you would be assigned a case manager who would discuss your case with your provider. For instance, if your provider only authorised your hospital stay for 3 days and you are still in hospital beyond those days, your case manager would communicate with your provider to let them know the reasons. Perhaps some complications were experienced and you need additional days the case manager and your provider will come to an agreement about how to cover your care. Sometimes there is admin happening in the background that you as the client won’t even be aware of. If supporting documents such as reports are required then your case manager will handle that. 

Due to digital systems in place, you may not even have to send a claim in. Once you have been to your GP/specialist your claims would be logged automatically after your visit.

Vivory Team: Can you explain the difference between "in-hospital" and "out-of-hospital" benefits in the medical aid context?

Michelle: In-hospital it is exactly just that. You have walked through the doors of the hospital, been assigned a bed in a ward and are now in hospital. There are certain benefits that would be covered for in-hospital treatments and your out-of-hospital benefits would apply to practices out of hospital such as GP visits, X-Ray departments etc. 

Vivory Team: What is the significance of "sub-limits" and "co-payments" in the context of lymphoedema treatment?

Michelle: Regarding the specific sub-limits for lymphoedema, I'll need to do some research to provide an accurate answer. However, I can explain the general concept of co-payments. If you're on a medical aid plan linked to a specific network of hospitals, and your oncologist isn't part of that network, you may have to pay a co-payment to receive treatment at an out-of-network hospital. This co-payment can range from R5,300 to R18,000. Similarly, for additional procedures like scopes or MRI scans, you might incur a co-payment. If you have gap cover, it can help cover these co-payments, depending on your specific plan.

Vivory Team: As a medical aid advisor, when would you recommend that somebody has gap cover?

Michelle: In my opinion you can't afford not to have gap cover in South Africa at the moment. To me it is a must have. I have seen some claims come in that can be financially debilitating. Because of a shortage of specialists in the country and non-regulated billing, some specialists can be charging in excess of 800%. Rather pay the additional couple of hundred rand per month to cover yourself. I’ve seen some people paying off their doctors or anesthetists months or even years after giving birth. 

Vivory Team:
How can patients effectively communicate with their medical aid providers regarding lymphoedema-related claims in South Africa?

Michelle:
Again, email them, phone them, get in there and ask questions. Don’t take the first no as an answer. I’ve been in this industry for a long time and I teach my staff not to take no for an answer, but you also need to know when you have received the final no.  

Vivory Team:
How can patients understand and interpret the terms and conditions of their medical aid plans?

Michelle:
There is no straightforward answer to this, my advice to patients would be that they understand what they are covered for. A hospital benefit may seem standard but there are benefits available that may not have been explained when taking out cover. 

Empower yourself, read through your documentation, look on your medical aid provider’s website, ask questions and don’t just take no for an answer.

If you have a condition and you’re not too sure that it’s going to be covered, send a claim in and see what they come back with. Don’t assume that because you don’t have a day-to-day benefit that you won’t be covered for a GP visit because sometimes you don’t know if it is a PMB or not. There may be funds within your medical aid that you are not sure about and can make use of. 

Vivory Team:
Thank you, Michelle, for taking time out of your schedule to share your extensive knowledge and valuable tips with us and our readership!

If you'd like to make contact with Michelle or one of her dedicated team members at Approach Administration, you can reach out them by giving them a call on +27 21 761 0488 or send them an email on info@approachadmin.co.za.