Oncology relates to the prevention, diagnosis, and treatment of Cancer. If the type of Cancer is considered a Prescribed Minimum Benefit (PMB), a Medical Aid Scheme is legally obliged to continue paying for treatment at cost, even if the oncology benefit limit has been reached. This can include covering the costs of consultations, surgery, specialized radiology, blood tests, chemotherapy, and radiation therapy.

WHEN IS CANCER CONSIDERED AS A PRESCRIBED MINIMUM BENEFIT?

As defined in the Medical Schemes Act, a cancer qualifies as a PMB if it is considered as ‘treatable’. ‘Treatable’ cancer is defined in the Medical Schemes Act below:

In general, solid organ malignant tumors (excluding lymphomas) will be regarded as treatable where:

(i) they involve only the organ of origin, and have not spread to adjacent organs

(ii) there is no evidence of distant metastatic spread

(iii) they have not, by means of compression, infarction, or other means, brought about irreversible and irreparable damage to the organ within which they originated (for example brain stem compression caused by a cerebral tumor) or another vital organ

(iv) or, if points (i) to (iii) do not apply, there is a well demonstrated five-year survival rate of greater than 10% for the given therapy for the condition concerned.

It is important to note that not all cancers of solid organs necessarily meet the requirements for PMBs, however, there are various cancers of non-solid organs and systems that qualify as PMB conditions – whether they are “treatable” or not. For example, acute leukemia, lymphomas, multiple myeloma, and chronic leukemia may qualify as PMB.

If a patient is diagnosed with a type of cancer which is not viewed as a PMB in terms of the current legislation, patients are then subject only to the oncology benefits and limitations set by the relevant medical scheme in each option.

Be sure to understand what your benefit covers, as not all schemes automatically provide cover for pathology and radiology services, radiotherapy, chemotherapy, and surgery from this limit.

OVERVIEW OF A FEW OF THE MEDICAL SCHEMES BENEFITS AS AT 2023

BONITAS:

• The limits for Oncology on Bonitas differ per option.

• The BonComprehensive, the Oncology Hospital Benefit amounts to R400 000 per family for non-prescribed minimum benefit conditions. Thereafter paid at 80% at a Designated Service Provider and no cover at a non-Designated Service Provider once limit is reached.

• BonClassic allows for up to R300 000 per family and 80% of cost thereafter.

• BonCap’s plan is limited to Prescribed Minimum Benefit conditions at a designated service provider and a 30% co-pay if a non-designated service provider is used.

DISCOVERY HEALTH:

Discovery’s oncology limits are allocated as follows:

• Executive and Comprehensive R500 000 over a 12-month cycle, thereafter 80% of cost.

• Priority, Saver, Smart and Core R250 000 over a 12-month cycle thereafter 80% of cost.

• KeyCare range covers Prescribed Minimum Benefit Oncology treatment at a Network Provider or an Allocated Specialist. Other Specialists will be covered at 80%.

FEDHEALTH:

• Fedhealth’s ‘Maxima Exec’ scheme option allows for up to R624 000 at a preferred provider, and then a designated service provider once the limit has been reached.

• FlexiFed range from R311 900 to R499 100 with FlexiFed 1 only covering Prescribed minimum benefits at a Designated Service Provider.

• MyFED’s oncology cover is limited to Prescribed Minimum Benefits. If a non-designated service provider is used a copayment of 25% is imposed.

• It is important to note that Fedhealth is the only Medical Aid that allows you to upgrade your plan within 30 days of diagnosis.

MOMENTUM HEALTH:

• Momentum’s Extender plan, Oncology threshold is R500 000 per annum, with a 20% co-payment thereafter.

• Momentum Health’s other options have a R400 000 annual benefit on their Incentive plan and R300 000 on the Custom Option.

• Their Summit option has unlimited benefits.

SIZWE:

• Sizwe’s Traditional comprehensive option Titanium Executive allows for up to R679 550 pb over a 12-month cycle. There is a co-payment of 80% of Cost thereafter.

• Across the rest of the product range namely Platinum Enhanced, Plus Plan, Gold Ascend and Access Saver the limit ranges between R218 400 and R682 500.

Please refer to the brochure of your relevant Medical Aid plan for more information.

This is a time when members and dependants need support, for more information and assistance, please free to contact us.