Does Medical Aid Cover Frail Care?

frail care

Aging can be an expensive life process, especially when medical aid benefits are not as substantial as they should be.

Chronic conditions are more prevalent, and costly medications are prescribed to regulate heart-rate, blood pressure, and other bodily functions.

One of the many age-related health issues we have to confront is physical and mental impairment.

Medical support and assistance for the elderly

Many of us may need support and assistance to carry out simple day to day tasks. Others may be totally incapacitated, and require professional 24-hour nursing care.

When that time comes, moving to a frail care facility is one option. Paying for professional home-based nursing services is another.

Both can be exceedingly expensive, particularly when you have elected to downgrade your medical aid after retirement. The question is; do medical aid schemes cover frail care? The answer is yes and no.

Long-term frail care: No

In general, open schemes in South Africa do not cover the costs of long-term accommodation and care in a frail care facility.

They do, however, pay for chronic medications, medical appliances, and GP and specialist consultations in line with a particular option’s benefit structure.

The key word here is ‘long-term’. Medical aid schemes are simply not in a financial position to cover the costs of frail care, home-based nursing or assisted living over an extended period of time.

Short-term medically-related frail care: Yes

When it comes to paying for a short period of rehabilitation and care by professional healthcare providers - at home or at a licensed and registered step-down facility - medical aid providers are more generous.

Most schemes provide limited benefits that cover the costs of medical rehabilitation, step-down facilities, and private nursing following a major medical event – a stroke, heart attack or bone fracture.

How schemes cover short-term frail care

Momentum Health, for example, covers short-term stays at step-down facilities on all its options. Cover is limited, and paid from major medical benefits.

Bonitas offers limited benefits for step-down facilities and hospice stays. Cover is paid from in-hospital benefits, and depends on the type of plan subscribed to.

Discovery Health has taken a different approach. South Africa’s largest medical scheme offers fully-paid home-based care services by qualified nursing staff.

The Home Care benefit is accessible to all scheme members, provided a GP submits an application to the scheme on your behalf, and the application is successful.

Palliative frail care: Yes

What happens at the end of life?

Almost all medical schemes in South Africa provide unlimited benefits for end of life palliative care Benefits usually apply across the option range, and care is covered at a hospice, in a frail care facility or at home.

Palliative care benefits usually pay for pain management medications, a caregiver, basic pathology services, and support for the member, and his or her family.

In a nutshell: frail care and medical aid

Here’s a brief synopsis of how medical aid providers in South Africa cover frail care:

  • Long-term frail care, either in a facility or through home-based nursing or assisted living, is not covered.
  • Short-term stays in registered step-down, acute or sub-acute care facilities are covered, provided they are related to a major medical event. Benefits are limited, and paid from in-hospital benefits.
  • Unlimited palliative frail care is covered at a hospice, frail care facility or similar.

Contact IFC medical aid brokers on 021 593 3012 to find out more about medical aid cover for frail care, and for objective advice about the best possible medical aid for your needs.

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