Prescribed Minimum Benefits for disabilities

Some time ago I discussed medical aid funding for the treatment of conditions that result in participation and mobility impairment. I want to return to the scene of the crime.

Colleen Swanson was injured 8 years ago and has a C7 spinal cord injury. Initially she used an indwelling catheter and bags to manage her bladder, but had constant problems with autonomic dysreflexia, blocked catheters and leaking. A year ago she had to have an ileal conduit urostomy (a new passage from the small bowel which drains through a hole in her abdominal wall into a urine bag stuck to her skin).

Since then she has fewer problems and her quality of life has improved significantly. Medical aid refused, but here is the shocker – For years her medical aid refused to authorize the cost of new catheters, bags and peripheral products as part of her “chronic medication” benefit.

They insisted that this be recovered from her “external appliance benefit” or her “savings account” – both of which were minimal and quickly exhausted. She had to pay for these items herself. This changed from year to year and sometimes she managed to get them to pay from an “ex-gratia” limit, but this still then depleted her “appliance limit”. Colleen started researching PMB limits in 2004 and wrote numerous letters to her medical aid explaining why all bladder and bowel meds and products should be regarded as PMB items. But they still refused to recognize this. Assuming the medical aid knew what they were talking about, she left it.The situation went from bad to worse after the urostomy.

While the medical aid authorized the procedure, they refused to authorize her essential incontinence products out of a PMB limit, which are more expensive than catheters, and that depleted her year’s savings within months. Colleen got mad. After some enquiries she found that Medical Schemes Act regulations overrule medical aid rules, and make provision for certain Prescribed Minimum Benefit (PMB) conditions and their treatment. The regulations state that “any benefit option that is offered by a medical scheme must pay in full, without co-payment or the use of deductibles, the diagnosis, treatment and care costs of the prescribed minimum benefit conditions”. The regulations explain this and allow the medical scheme to appoint a Designated Service Provider (DSP) such as a public hospital where members can obtain services, medication and supplies.

It’s important to check if there is a formal arrangement between the medical aid and a DSP, as some schemes automatically dump patients on the over-burdened state health system. They cannot. The regulations state that “Where the treatment is stated in general terms (i.e. “medical management” or “surgical management’), it should be interpreted as referring to prevailing hospital-based medical or surgical diagnostic and treatment practice for the specified condition. Where significant differences exist between Public and Private sector practices, the interpretation of the Prescribed Minimum Benefits should follow the predominant Public Hospital practice, as per state clinical protocols, where these exist.

Where they do not exist, disputes should be settled by consultation with provincial health authorities to ascertain prevailing practice.” Colleen wrote to her nearest state hospital asking them to declare whether it was routine practice to provide their SCI patients with catheters and bags (urostomy supplies in her case). They replied yes, and listed the items they supplied monthly. She then complained to the Medical Schemes Council (MSC) who reviewed her case. Her medical aid’s reply to the MSC maintained that they did not consider the items as PMB’s.

Colleen appealed and the MSC, on review, judged in her favour. They said that SCI was indeed a PMB condition and that catheters, bags, meds etc. should be covered without restriction of co-payment by the medical aid, regardless of benefits and restrictions in the rules. She now pays from a PMB benefit for all urinary bags, urostomy supplies, bowel medications, linen savers, gel and gloves.

Fought back

This saga should never have happened. Colleen’s story is no different, except that she fought back. Day-to-day life is hard enough without inept, callous and indifferent medical scheme bureaucrats cutting costs at the expense of delivering essential medical care. If you have a disabling condition and your medical aid will not pay for your medicines, supplies, treatment and equipment (they should but won’t admit it), seek help from the Council for Medical Schemes (www.medicalschemes.com).

Colleen researched what to send to the Council to support her complaint. This included a motivation letter from her doctor (why the products are needed, etc) complete with ICD10 code and PMB code. The PMB code she used is 213A which states: “Difficulty in breathing, eating, swallowing, bowel or bladder control due to non-progressive neurological (including spinal) condition or injury.

Treatment:

“Medical and surgical management; ventilation”.ICD10 codes G81.0 to G82.5 cover SCI, and N31.0 to N31.9 cover urological conditions. A doctor should be able to provide the correct codes for specific conditions.She also needed a detailed prescription for everything she was using for her SCI, including a description of each item, the Nappi Code, price per item and quantity required per month. This was supported by a letter from a large state referral hospital confirming that they routinely supplied these items to state patients who have the same condition.

Finally she had to explain what a PMB is, confirm that she has a PMB condition and state how PMB’s are meant to work.It took her two years of complex, technical slog – far too imposing for most people who usually just give up. I encourage SCI-disabled people to take up this issue. They are welcome to contact me for advice. You have a right to correct and appropriate treatment, and you are entitled to stand up and be counted. Perhaps QASA and other organizations can help “automate” the process.Dr. Rob Campbell - rob@aurorahospital.co.za

Colleen Swanson - cswanson@worldonline.co.za

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