Medical Aid Schemes that Cover Schizophrenia

SchizophreniaSchizophrenia is a chronic mental illness that requires lifelong treatment and support. Both psychotherapy and prescription medications are typically used to manage the condition.

Prescribed minimum benefit condition

The Medical Schemes Act has defined schizophrenia as one of 270 Diagnosis and Treatment Pairs (DTPs) entitled to prescribed minimum benefits (PMBs). This means that medical aid schemes in South Africa are legally required to cover the cost of treatment, which in the case of schizophrenia includes hospital-based medical management for up to three weeks per year. All beneficiaries, irrespective of their level of cover or medical aid plan options, are entitled to this benefit.

To manage the costs associated with PMBs, medical aid schemes can insist that members use designated service providers (DSPs); network hospitals, pharmacies and specialists, or even state facilities, depending on the level of cover.

Chronic Disease List condition

Schizophrenia is one of 25 conditions on the Chronic Disease List (CDL). For all CDL conditions, minimum standards of treatment are specified. These are published in the Government Gazette.

All medical aid schemes have to cover the cost of medications, consultations once approved under chronic. However, they’re entitled to make use of formularies, treatment protocols and DSPs to manage their costs.

The degree of chronic cover provided depends on the type of cover a medical aid member has. Typically it’s proportionate to the member’s monthly contribution. For example, premium plans typically pay for extended medicine formularies or out-of-formulary medications, private hospitalisation and consultations with any healthcare providers. Entry-level options may cover only low-cost generic medications purchased at network pharmacies, consultations at DSPs and hospitalisation at state facilities.

Below we consider the benefits that two South African medical aid schemes offer for PMB and CDL conditions such as schizophrenia.

Medshield

Medshield offers a structured and methodical approach to CDL conditions through its Chronic Medication Management Programme.

Registered members have access to medications covered by the chronic medication benefit, and are subject to the programme’s treatment protocols and clinical guidelines.

The scheme covers the cost of medicines that appear on the Medicine Price List (MPL) for your plan. This may include generic medicines only. However, high-level plans offer more comprehensive formularies that include both generic and branded medicines.

A medicine access card lists all medications covered by a member’s chronic medicine benefit.  In addition, Medshield offers in-hospital mental health benefits for members with schizophrenia. These benefits differ according to plan. Out-of-hospital consultations and treatment are also covered up to a certain limit.

Resolution Health

Resolution Health has a Chronic Disease List Benefit Programme that covers the cost of chronic medication, three follow-up consultations and two specialist consultations per year for members diagnosed with schizophrenia.

Prescribed medications are subject to the appropriate plan’s formulary, and a generic reference price list applies. DSPs must be used to avoid co-payments.

To complement its chronic disease benefit, Resolution Health offers in-hospital cover for psychiatric conditions across all of its plans. Benefits are limited to network healthcare providers and subject to PMBs and scheme treatment protocols.

In addition, the scheme offers limited out-of-hospital benefits for psychological and psychiatric treatment. Cover varies from plan to plan. The high-level Supreme option, for example, offers cover up to R1,350 per family at 100% of the scheme rate, subject to an annual limit. The entry-level Foundation option offers cover limited to PMBs at DSPs only.

For more information about South African medical aid options and the benefits they offer members with schizophrenia, contact one of our independent financial consultants.