When your emergency is not paid by your medical scheme

Don’t rush off to the emergency room too quickly – it may cost you more than you realise.

When your emergency is not paid by your medical schemeA recent twitter rant by a Discovery Health Medical Scheme member highlighted an often-misunderstood fact about hospital plans: they don’t cover visits to the emergency or casualty rooms.

Many hospitals have outsourced the function of the emergency room to private practice which means it does not form part of the hospital. So being admitted into hospital is different from being treated in casualty, according to Discovery Health.

One is treatment as an in-patient and the other is an out-patient or out-of-hospital treatment, regardless of whether the casualty rooms are based at the hospital or not. When a member has a planned admission for treatment in-hospital, they will be admitted into a ward. A member can also be admitted into the ward from the casualty facility should the casualty doctor deem it necessary. When a member is admitted into hospital, they will be taken to a ward and an authorisation will be obtained from the Scheme. If the person is treated in the casualty rooms and thereafter able to go home, this is not an admission – this is treatment which was received via an out-patient facility.

While this issue is particularly relevant to members of hospital plans, the same rules would apply to a member where the medical savings have been depleted. Unless the scheme offers a specific emergency benefit, the visit to the ER would be paid from your medical savings, so if they are depleted, you would be paying from your pocket.

However, medical schemes are obliged to cover emergencies as part of the Prescribed Minimum Benefits (PMB) and if the member is admitted to the ER for a genuine emergency, then it could be covered under the hospital plan. But what constitutes an emergency is not always clear.

Confusing for members

Damian McHugh, head of health marketing and growth at Momentum acknowledges that this can be very confusing for members who would not actually know, when they arrive at the ER, whether or not their bills will be covered by their hospital plan.

“If we fully covered all visits to the ER, people would abuse it and use it for day-to-day events that are not covered under a hospital plan,” explains McHugh who says as a general rule, if you are on a hospital plan and you visit the ER, you won’t be covered by your medical scheme.

Some hospital plans, however, may provide for a limited amount of consultations at medical practices, which can mean that in some cases your ER visit may be covered, so you need to read your  benefit guide for clarification. “It is important to note that there are instances where a medical scheme’s definition of an emergency differs from that of a consumer’s – which the consumer won’t reasonably know as general knowledge.”

For example, if you fall and bang your head and require stitches, that may not be considered an emergency. However, if you are vomiting and concussed and need an urgent medical examination, that could be considered an emergency even if you are able to go home the same day without being admitted to hospital.

“From a medical scheme’s perspective, we can only rely on the code we received from the ER to determine whether or not it was considered an emergency,” says McHugh.

That doesn’t mean that you cannot question the decision, and if you feel that it was a genuine emergency, you need to contact your medical scheme to argue your case.

According to Discovery Health, members can complete the out-of-hospital management of a Prescribed Minimum Benefit condition form, where the casualty account can be reviewed for cover. “Cover for these acute out-of-hospital PMB conditions, typically once-off events, requires an application for funding, following the event. This application process is necessary, as the information initially received by the Scheme with the first claim is generally limited to the ICD-10 and tariff codes on the claim only. This information is not sufficient to establish a reliable diagnosis and the Scheme often requires additional clinical information or confirmatory evidence to determine whether the circumstances of the case actually meets the definition of PMB or emergency PMB,” explains CEO of Discovery Health, Dr Jonathan Broomberg who says that where the Scheme becomes aware after the event or is subsequently informed that the event qualifies as an emergency, all claims related to such admission are reviewed and processed in accordance with the PMB regulations.

Emergency rooms charge much higher fees than your local GP, so you need to consider carefully whether or not this would constitute a genuine emergency before rushing yourself or your child to the ER. A good rule of thumb is whether or not your local GP would be able to attend to the problem.

A heart attack, broken limb or car accident where you are brought in by ambulance would most likely make the emergency list. If your GP refers you to the emergency room, there would be a good chance it would be covered.

It is worth noting that some schemes do provide cover for non-PMB emergencies. For example, Fedhealth offers its members unlimited trauma treatment at a casualty ward, paid at 100% of the Fedhealth rate with a co-payment of R570 per non-PMB visit.

Understand your hospital plan

Hospital plan benefits vary between medical schemes, so it is important to understand what cover you have, or don’t have. Hospital plans pay at different in-hospital rates, for example some pay only 100% of the medical scheme rate while others pay at 200%.

You also need to check how many PMBs are covered by your hospital plan. Jill Larkan, head of healthcare consulting at advisory firm GTC says some schemes offer benefits above the 26 PMB chronic illnesses and may include additional preventative or primary healthcare. “61% of all hospital plans provide pre-natal maternity consultations from risk, even though they are pure hospital plans, whilst 32% provide post-natal consultations and 46% even provide paediatric consultations,” says Larkan who adds that 34% of hospital plans offer contraceptive benefits as well, even those these have nothing to do with hospitalisation and that 22% of plans offer specialised radiology cover outside of hospital.

You also need to check what post-hospitalisation benefits you receive. For example, you may have been admitted to a hospital for a car accident and require physiotherapy after being discharged. As this would be an out-of-hospital treatment, it would not fall under hospital treatment. Some hospital plans include a 30-day rehabilitation benefit, so make sure you know what cover you have, and what you don’t have.

Also, be aware of exclusions on your hospital plan. For example, most hospital plans will not cover cosmetic procedures, frail care or self-inflicted injury. There may also be co-payments on elective procedures such as a hip replacement.

“Authorisation is the key to getting the best cover from your medical aid. You will also find that, for elective procedures, you, your doctor, and the hospital, all end up phoning the medical aid for an authorisation reference number for the procedure. This is good for members, as should the elective procedure carry a co-payment, or not be covered because of a general or plan-specific exclusion, you will find out at that point. The authorisation note will state this and list the co-payment amount,” says Larkan.

Can you supplement your hospital plan?

According to Larkan, there are two levels of supplementary cover which you can consider if you have chosen to belong to a hospital plan only.

The first and most important additional level of cover would be the top-up/gap cover plan. These will enhance your in-hospital cover level, where your medical aid restricts cover to their set “medical aid rate”. This enhancement could be by/or up to 500/700% of the medical aid rate, covering in-hospital events. These can also offer additional emergency room cover of between R1 000 and R15 000 per annum to assist with these costs. MRI and CT scans may also be additional benefits provided and covered by top-up/gap policies, which may also come in handy during an emergency. Many other additional benefits may be provided by top-up/gap policies such as step down facility benefits, oncology benefits, accidental dental benefits, trauma counselling etc.

The second would be primary care benefits. These would be for day-to-day doctor visits, dentists, Xrays, medicines etc, provided by a specific network of providers, at very low premiums. These are not medical aid plans and in many cases the benefits/visits are limited or provided on a formulary. This means that you may only have a certain number of visits at a specific list of doctors, who can provide you with medication from a special limited list, until those set limits are exhausted. This cover would take care of your basic day-to-day healthcare requirements, as long as nothing serious happens to you.

This article first appeared in City Press.

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