Medical Aid Schemes that Cover Bronchiectasis

bronchiectasisBronchiectasis is a chronic lung condition that affects all ages and demographics. There is no cure – medical management focuses on improving quality of life.

Bronchiectasis is one of several diseases identified as a Chronic Disease List (CDL) condition that’s eligible for state-enforced Prescribed Minimum Benefits (PMBs).

What are PMBs?

With input from healthcare professionals, the South African government has identified treatment protocols deemed to be appropriate for managing CDL conditions, such as bronchiectasis.

The idea is to ensure that consumers of medical aid products have access to specified minimum healthcare services when they need it the most, notwithstanding their levels of cover.

To manage costs associated with PMBs, medical schemes are permitted to require members to use designated service providers (DSPs) and medication that’s specified on medicine lists, or formularies.

Members who belong to low-cost, entry-level plans are typically required to use state or network hospitals, consult with healthcare professionals who belong to their scheme’s network and use generic drugs that appear on the scheme’s formulary.

Top-tier comprehensive plans usually cover the costs of private hospitalisation, consultations with healthcare providers of members’ choice and a more extensive list of medications, including branded medications.

Resolution Health Medical Scheme and bronchiectasis

In the case of bronchiectasis, PMBs apply for specific diagnostic investigations and tests.

Resolution Health medical scheme, for instance:

To qualify for these bronchiectasis-related chronic benefits, members have to ensure that the correct diagnostic code, known as an ICD-10 code, has been submitted to the scheme’s disease management programme

PMB cover for the symptoms and complications of bronchiectasis

Complications associated with bronchiectasis, such as recurring infections, abscesses of the lungs, respiratory failure, collapsed lung and heart failure, are deemed PMB conditions in their own right and are published as diagnosis and treatment pairs.Medical aid schemes have to cover the costs relating to the treatment and care of these, and other, side effects if they qualify as PMB’s.

Why additional cover is essential

Many of the most successful interventions are those that treat the underlying causes and resultant infections of the disease. Members with bronchiectasis ideally need cover for:

  • annual flu and pneumonia vaccinations
  • bronchodilators to improve air flow
  • antibiotics to treat infections
  • breathing exercises, draining of the lungs and physiotherapy of the chest.

Resolution Health - Summit Option

Members who register for Resolution Health’s top Summit option enjoy comprehensive healthcare benefits that far exceed the PMBs. These can go a long way toward relieving the financial stresses associated with chronic diseases.

How medical aid schemes fund chronic medications

Chronic medication has to be taken on an on-going basis. Lower-level plans typically cover the cost of less expensive generic drugs from a designated service provider, provided these drugs appear on the scheme’s formulary.

If a member opts to use out of formulary medications, the scheme may cover only a portion of the cost or none of the cost at all.

More expensive plans provide more comprehensive chronic disease benefits. Covered medications on these plans usually aren’t limited by a formulary and may be dispensed at a pharmacy of choice.

Fedhealth chronic disease benefit

As an example, Fedhealth’s premier Maxima Plus has a chronic disease benefit limited to R12 900 per beneficiary, subject to an overall annual limit of R24, 100 per family. It covers 51 chronic conditions.

In the entry-level Maxima Entry Zone, there’s cover for medication relating to PMBs on a restrictive formulary and at a designated service provider only.

Although all medical schemes in South Africa cover the basic costs associated with the treatment and care of bronchiectasis, it’s advisable to upgrade to a more comprehensive plan that offers the best possible cover and the widest range of personal choice.

Chat to an IFC consultant about your special healthcare requirements and we’ll assist you in finding the options that suit you best.