Your scheme and breast cancer – 10 questions to ask

After chemotherapy from Shutterstock
After chemotherapy from Shutterstock

One in 27 SA women will get breast cancer at some time during their lives. If you’re a medical scheme member, you need to find out exactly what your scheme will pay for, and what it won’t.

According to the Cancer Association of South Africa, breast cancer is the most common cancer among women. If you are in a high-risk category for breast cancer, you need to find out whether your scheme provides you with sufficient cover, should you be diagnosed with this disease.

Read: New breast cancer drug shows 'unprecedented' results

Most medical schemes will pay for one mammogram per year and scheme members are encouraged to use this benefit. Also consider the BRCA gene test – and find out if your scheme will pay for it. The earlier a cancer is detected, the greater the chances of successful treatment.

Generally breast cancer is not treated differently to other types of cancer by your medical scheme. Here are answers to questions on how much and when schemes pay for cancer treatment, breast cancer in particular.

What treatment will my scheme pay for?

Treatable breast cancer is a prescribed minimum benefit (PMB), but not all cancers are. In other words your scheme has to pay for the diagnosis, treatment and care costs of your breast cancer, whatever medical scheme option you are a member of.

This would include surgery, consultations, radiology, pathology, chemotherapy and radiation therapy, according to the Council for Medical Schemes.

What is a treatable cancer?

If you have cancer of a solid organ that is treatable, it qualifies as a PMB if it can be treated. This means that it hasn’t spread to adjacent organs, or to distant organs, or caused incurable damage to the organ in which it has originated.  (Medical schemes will pay for treatment of some systemic cancers, such as leukaemia if it is listed as a PMB.)

What must I do to alert my scheme if I have cancer?

Phone your medical scheme administrators immediately.

You will have to get pre-authorisation for treatment if you want your scheme to pay for your treatment. They can also require that you enrol in an oncology programme.

Contact them by telephone – faxes are great as supporting documents, but then you don’t have the name of a consultant to use if you run into any trouble. Also remember that many of these calls are recorded.

What happens if my cancer is not treatable?

If the cancer has spread to the rest of your system, but it can be proved that at least 10% of people with the same severity of cancer have lived longer than 5 years after treatment, your cancer will be treated as a PMB. If not, the oncology limit on your specific option will kick in.

This depends on your scheme, and the option you have chosen. Some low-cost hospital plans will only pay for cancer treatment if it is a PMB – if not, you are on your own.

Medium-cost plans to fully comprehensive plans will usually pay anything from R200 000 to R500 000 on the oncology limit. If you reach the limit, most of them will carry on paying, but can charge you a 20% co-payment.

Can my scheme tell me where to go for treatment?

Yes, and no. You can choose your own doctor, but if the doctor you have chosen charges more than the scheme rate, you will have to pay the difference.

It is always better for your own pocket, to use a designated service provider (DSP) – both a doctor and a hospital or treatment facility, as your bill could be fully covered. If you do not have a DSP close to where you live, you need to negotiate with your scheme administrators before you have any treatments, otherwise you could end up with big co-payments.

Can my scheme prescribe which treatments I have?

You and your doctor can choose which treatments you will have, but you have to submit a treatment plan to the scheme. This will be evaluated according to certain medical protocols that each scheme has.

This can be a bit of a grey area. If you feel your scheme is not playing fair, check with the Council for Medical Schemes what the law requires. Their Call Centre number is 0861 123 267 and they are open from 08h00 to 17h00 Mondays to Fridays.

How does the oncology limit work on my scheme?

Obviously every scheme’s oncology limit works differently. Some will only pay for cancer treatments of a PMB, others will provide a fixed sum of money they will pay for treatment of cancers which are not PMBs.

This is usually between R200 000 and R400 000, sometimes more. After that, a co-payment of 20% will be payable by the member. Check with your medical scheme to see which cancer services they will pay for – these are usually specified very clearly, down to the number of consultations, X-rays and blood tests in a particular basket of care.

Read: How the funds of medical schemes are spent

This is often decided in conjunction with the South African Oncology Consortium. If you have a complex cancer, you could qualify for an extended basket of care. Phone your scheme today to get the details.

Can the scheme specify which medication they will pay for?

Yes, they can. Schemes will generally carry the cost of cancer medication used by the state to treat cancer. If you want to use a more expensive medication, you can be asked to pay the cost difference between the two.

What about expensive drugs such as Herceptin for breast cancer?

The costs of so-called biological drugs can run into hundreds of thousands of rand per year per scheme member who has specific cancers. Smaller schemes could struggle to carry these costs, but if there is no alternative treatment, and the cancer is a PMB, the scheme will have no choice but to pay.

In smaller schemes these payments could have a serious effect on other scheme members and on the reserves of the scheme. Usually, before any scheme will consider paying for biological drugs for one of its members, very specific clinical guidelines will be followed. Many schemes are now introducing a separate benefit for high-cost drugs such as these.

What is dread disease cover?

This is a medical insurance and falls outside of the jurisdiction of the Medical Schemes Act. If you have dread disease cover, it means you have taken out insurance that will pay you out a lump sum of money if you are diagnosed with a debilitating disease.

Most claims in SA are for cancer, heart attacks, strokes and coronary artery bypass grafts. Seventy-five percent of dread disease claims for women are cancer-related, with 70% of these claims being for breast cancer, according to PPS (Professionals Provident Society of South Africa).

Read: Angelina Jolie inspires rise in breast cancer testing

You cannot take out dread disease cover after you have been diagnosed. Take note that dread disease cover does not pay for your medical costs, but you are free to use the money in whatever way you see fit.

You choose how much cover you want, so premiums differ widely. The severity of your disease often also determines the amount you get paid. An insurance broker should be able to give you the information you need.

Read More:

Medical scheme dependants: who qualifies?
Early detection key in breast cancer recovery
Beware of medical insurance scams

Image: After chemotherapy from Shutterstock.

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