Medical Aid Schemes that Cover Crohn’s Disease

chron's diseaseCrohn’s disease is an inflammatory bowel disease that can cause abdominal pain, diarrhoea and fever, as well as complications such as bowel obstruction and skin rashes. Osteoporosis, colonic cancer, anal fissures and bleeding, recurring mouth sores and eye problems are also prevalent in those with Crohn’s disease.

Although there isn’t a known cure, appropriate medical management can result in long periods of remission, with just occasional recurrences referred to as flairs.

Treatment typically comprises:

  • a combination of antibiotics, steroids, immunomodulator drugs, sulphasalazine, biologic response modifiers and 5-aminosalicylates, depending on the affected area of the digestive tract and the patient’s symptoms
  • dietary interventions – consultations with a dietician, and the development of a suitable daily diet can be helpful. Some raw and processed foods may intensify the symptoms and associated pain and discomfort
  • lifestyle changes – smoking, lack of exercise, poor nutrition and the use of non-steroidal anti-inflammatory (NSAID) medications may increase the occurrence of flairs
  • surgery as a last resort, or as necessary to manage side-effects such as internal bleeding or bowel obstruction.

A comprehensive medical aid plan, with adequate cover for both ongoing investigative tests and treatments, is the most appropriate solution for those who have Crohn’s disease.

What do medical aids cover?

In South Africa, Crohn’s disease is identified by the Medical Schemes Act as a Chronic Disease List (CDL) condition that’s eligible for state-endorsed Prescribed Minimum Benefits (PMBs). This means that by law, all medical aid schemes are required to cover costs associated with the diagnosis, treatment and care of the condition (after any applicable exclusions and subject to approval).

However, medical aid schemes are entitled to require members with Crohn’s disease to limit covered medications to those included on formularies (medicine lists) they create. They may also insist on treatment only by designated service providers (DSPs) – healthcare providers, pharmacies and hospitals that are part of their networks.

Chronic medication listed on a scheme’s formulary is covered by a chronic benefit. For members of premium plans, formularies are extensive and chronic medication is typically covered in full. Those on lower-level plans or who choose to use out-of-formulary medicines may have to make co-payments.

PMBs include cover for the costs of initial diagnostic tests. Depending on the affected area of the gut, these may include colonoscopies, gastroscopies, biopsies, barium enemas or meals, MRI or CT scans and blood tests. However, they don’t necessarily cover adequate follow-up examinations or procedures.

The complex nature of Crohn’s disease often leads to secondary health complications, such as inflammation and poor nutrition. Osteoporosis, colonic cancer, anal fissures and bleeding, recurring mouth sores and eye problems are also prevalent in those with Crohn’s disease.

To offer more insight into the cover that South African medical aid schemes provide for members with Crohn’s disease, we explore the benefits offered by two medical aid schemes – Momentum Health and Resolution Health.

Momentum Health

momentum healthMomentum Health members with CDL conditions such as Crohn’s disease have to register with the appropriate disease management programme and request authorisation to qualify for chronic benefits.

At present, the Momentum Health formulary lists various types of medications for Crohn’s disease. Costs for these are covered either partially or in full depending on members’ plans.

High-end plans, such as the Summit option, cover the costs of chronic medication – including branded medications as well as the generic forms – in full.

In addition, the Summit option offers:

  • unlimited in-hospital cover at any hospital
  • seven days supply of “take home” medications
  • extensive day-to-day and chronic benefits at a healthcare provider of choice
  • cover for MRI and CT scans, in and out of hospital, with no annual limit; however, co-payments apply
  • cover for 53 specialised procedures, in and out of hospital, such as scopes
  • day-to-day cover for dieticians, osteopaths and other alternative healthcare providers, limited to R5,400 per family
  • radiology and pathology, subject to the overall day to day limit
  • Cover of up to R14, 600 per beneficiary for prescribed medicines.

The entry-level Ingwe option provides members with the same formulary, but a reference price list covers the maximum prices of various medications and members are required to make co-payments.

The Ingwe option offers in-hospital cover up to R1 million per family per year, at any state, private or at designated hospitals (depending on the option selected which will determine price). Chronic and day-to-day benefits are restricted to network providers. Cover is provided for PMB associated MRI and CT scans, 19 specialised procedures (in or out of hospital) and seven days of take home medication.

Resolution Health

resolution healthResolution Health provides cover for Crohn’s disease-related investigations on all options, provided the diagnosis is made by a specialist physician, paediatrician, surgeon or gastroenterologist (after any applicable exclusions and subject to approval).

Members are required to register for the Chronic Disease List Benefit Programme, medication is subject to the appropriate plan formulary and a generic reference price applies.

The Resolution Health formulary lists various medicines commonly used to treat Crohn’s disease and associated complications. Costs for these are covered either in part or in full, depending on members’ level of cover.

The high-end Supreme plan offers unlimited in-hospital benefits at 100% of the scheme rate at private hospitals, including cover for X-rays and pathology. Specialised radiology is covered at the scheme rate, but a co-payment may apply for certain procedures.

Limited day-to-day cover is provided for alternative healthcare, radiology, pathology and GP and specialist consultations, providing pre-authorisation is obtained and visits are PMB-related.

For a medical aid quote or more information about South African medical aids that provide extensive cover for members with Crohn’s disease, contact one of our IFC representatives.