Medical Aid Schemes that Cover Cardiac Failure

cardiac arrestCardiac or heart failure is a serious condition that affects the heart’s ability to pump blood around the body. If not managed properly, it can lead to premature death.

A combination of medications and lifestyle changes are required to arrest the development of heart disease.

In South Africa, cardiac failure is one of 270 diagnosis and treatment pairs (DTPs) eligible for Prescribed Minimum Benefits (PMBs). In addition, it is a Chronic Disease List (CDL) condition and so qualifies for mandatory chronic medication benefits.

This means that irrespective of members’ levels of cover, all medical aid schemes in South Africa have to cover the costs associated with the diagnosis, treatment and care of beneficiaries with cardiac failure if the condition is diagnosed and after any applicable exclusions.

Medical aid cover for diagnostic tests relating to cardiac failure

Once the attending doctor has submitted the diagnosis, along with the corresponding ICD-10 code, to a member’s scheme, the member qualifies for the PMBs if the condition is in fact diagnosed and after any applicable waiting periods (exclusion) depending on the criteria of the waiting periods imposed.

In the case of the ICD-10 not matching the diagnosis, benefits won’t apply.  

How chronic illness benefits work

To qualify for chronic illness benefits, members have to register with the appropriate chronic disease management programme.

In-formulary medicines, which are those that appear on a scheme’s covered medicine list, typically consist of generic options or are subject to Generic Reference Pricing (GRP) - the maximum amount the scheme will pay for medicines within a specific generic class. Also, the covered medicines must typically be dispensed by a designated service provider or network pharmacy in some cases.

Members who opt for out-of-formulary, more expensive branded medications can do so in most cases but co-payments will apply.

Cardiac failure medicine classes covered by Liberty Medical Scheme

Some of the leading South African medical aid providers far exceed the PMBs for cardiac failure. As an example, Liberty Medical Scheme covers the cost of literally dozens of medicine classes and generics appropriate in the treatment of cardiac failure on their comprehensive options.

Why opt for more expensive medical aid cover?

Although the basic diagnosis, treatment and medical management of cardiac failure is covered by all medical aid schemes, more expensive, comprehensive plans provide greater freedom of choice.

Members on comprehensive plans aren’t restricted to using low-cost generics; they can pick and choose from branded medications, without being restricted by formularies in most cases. Investigative tests are covered in full, whether conducted by a network professional or not, and if hospitalisation is required, cover is provided for any private hospital or clinic.

Why not speak to a friendly IFC consultant today to discuss how best to protect you and your family from the adverse effects of chronic conditions, such as cardiac failure.