Join forces against HIV with your medical scheme

Source: Council for Medical Schemes

November 2008

All the clinical and private information necessary to participate in disease management programmes has to be treated as confidential by the operators (medical scheme or managed care organisation) of the programme.

HIV is a PMB. No, this is not a rap song's lyrics; however, these acronyms are sure to put a bounce in your step when you see what they can do for your health and your pocket.

HIV/Aids is a disease that strikes fear in people's hearts. The one important message to get across, however, is that a positive test result is not a death sentence. Medical schemes are increasingly geared towards giving people living with HIV/Aids that much‐needed extra bit of support for a healthy and productive life.

Most medical schemes in South Africa make specific provision for the treatment of HIV – provided that members declare their status. As with any other medical condition, your scheme can only make the benefits available to you if they know that you are suffering from the particular disease.

By disclosing your HIV status to your medical scheme, you might qualify for more benefits than when you seek treatment for the individual symptoms or opportunistic infections associated with HIV/Aids.

However, the stigma associated with HIV/Aids in our society makes it very difficult for people to disclose their status and seek help. According to the Council for Medical Schemes, scheme members' privacy is protected by the Medical Schemes Act. The scheme and its contracted parties, such as doctors and pharmacies, may not share any information about a beneficiary with anybody else, be they employers, spouses or even the main member. All clinical information, including a person's HIV status, has to be treated as confidential.

But what about the medical scheme statements that are sent to the main member – don't they reveal what a person was treated for? Definitely not, says the Council spokesperson. The statement only lists the service provider(s) involved, such as the GP, specialist or pharmacy, and in some cases the medication prescribed. Unless someone goes to great lengths to find out what a particular drug is for, the patient's illness remains between her and the service provider.

PMB benefits for HIV/Aids

Voluntary counselling and testing
Provision of co‐trimoxazole as preventative therapy
Screening and preventative treatment for TB
Diagnosis and treatment of sexually transmitted infections
Pain management in palliative care
Treatment of opportunistic infections
Prevention of mother‐to‐child transmission of HIV
Post‐exposure preventative care following occupational exposure, such as a nurse receiving a needle prick, or sexual assault
Medication, including the provision of anti‐retroviral therapy
Ongoing medical management, including the monitoring of medicine effectiveness and safety, to the extent provided for in the national guidelines applicable in the public sector

The benefits of managed care

As with other chronic conditions, such as diabetes and hypertension, your medical scheme could require that you join a disease management programme. These programmes aim to improve the health of members by helping them to monitor and manage their illness, providing them with information and education and, very importantly, lending them moral support.

Apart from the standard PMB‐related benefits, HIV/Aids disease management programmes also provide members with access to:

a network of professionals for pre‐and post‐testing counselling;
a network of doctors and specialists who are experts in the management and treatment of HIV/Aids;
specific interventions at specific intervals, such as pathology tests, necessary to monitor both the treatment and progress of the disease;
reminders to go for tests and consultations;
a network of hospitals for the treatment of HIV/Aids related illnesses;
anti‐retroviral therapy and other treatments for, for example, opportunistic infections, according to the scheme's formulary.
The programme might make use of DSP pharmacies or courier
pharmacies for participants in remote areas; and
HIV/Aids‐specific call centres, mostly operated by registered
nurses, for assistance with benefit queries, disease education
and any additional information regarding aspects of the disease
such as diagnosis, treatment side effects, caregiver support etc.

A significant advantage is that your scheme will ensure that the above‐mentioned services are paid for from the correct benefit limits as long as you participate in the programme. In this way, no claims will be paid from your savings account and your HIV‐related expenses will be covered if your other benefit limits have been exhausted.

HIV as a PMB – what it means for you

Apart from being specifically provided for by most schemes, HIV/Aids is also a PMB condition. Prescribed minimum benefits (PMBs) are treatments that your medical scheme has to cover, regardless of your membership option. In terms of the Medical Schemes Act, these are the costs related to the diagnosis, treatment and care of any emergency medical condition, a limited set of ±270 medical conditions, and 25 chronic conditions. HIV/Aids is included on the chronic conditions list. This means that your HIV treatment has to be covered even when your normal chronic benefits have run out.


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