The Chronic Illness Benefit
Retail Essential Plus and Essential
Medicine cover for Chronic Disease List conditions
The Chronic Illness Benefit covers approved medicine for the 26 Prescribed Minimum Benefit (PMB) Chronic Disease List (CDL) conditions. Approved medicine on the Chronic Illness Benefit medicine list (formulary) will be funded in full up to the Scheme Rate. Medicines not on the medicine list will be funded up to the monthly Chronic Drug Amount (CDA).
Treatment baskets for your approved Chronic Disease List conditions
The Chronic Illness Benefit will also cover a limited number of selected tests, procedures and specialist consultations each year for the ongoing management of your condition(s). You also have cover for four (4) GP consultations related to your approved PMB CDL condition(s) per year.
How to access the Chronic Illness Benefit
If you want to access cover from the Chronic Illness Benefit, you must apply for it. You must complete a Chronic Illness Benefit application form with your doctor and submit it for review. If your doctor uses HealthID, your doctor can apply for cover online, provided you have given your consent.
You need to meet the benefit entry criteria for your condition(s) to be registered on the Chronic Illness Benefit. You or your doctor may need to provide certain test results or extra information as indicated on the CIB application form for the condition(s) you are applying for. Please ensure that these documents are submitted with your application to avoid any delays in the process.
Documents for your Chronic Illness Benefit (CIB) cover:
Prescribed Minimum Benefits (PMB)
By law all medical schemes in South Africa must cover a minimum set of medical treatments for certain conditions. This is true even when scheme exclusions apply, when we have applied waiting periods in certain circumstances or when you have reached a limit for an applicable benefit. The Prescribed Minimum Benefits (PMBs) is a package of minimum clinical benefits that the Scheme must pay for. Your available Medical Savings Account (MSA) cannot be used to pay for these benefits.
The Prescribed Minimum Benefits consist of:
- Any life-threatening emergency medical condition
- A defined set of 271 diagnoses,
- And 27 chronic conditions, (including HIV and AIDS)
We will pay for PMBs in full only if treatment is provided by, or at one of the Scheme's Designated Service Providers (DSPs), except in emergencies, unless otherwise indicated.
Tests, procedures and consultations
You do not pay for the diagnosis and medical management costs provided in the baskets of care. These costs are paid in accordance with the Rules of the Scheme from your Core Benefits. Unless approved with further motivation by your doctor, we will pay benefits exceeding those provided for in the baskets of care from your available day-to-day benefits.
The cost of any treatment that is not in accordance with the basket of care may be covered from your available day-to-day benefits that are paid from the Core benefits, or you may have to pay for it, unless it is approved by DiscoveryCare, on appeal.
When you have just joined the Scheme, Retail Medical Scheme will not pay for the treatment of these conditions when a general waiting period applies to your membership, or when a 12-month waiting period applies for the specific condition. If your membership was activated without waiting periods, you have cover for these conditions from day one.
When co-payments for PMB medicine will not apply
- Your treating doctor submits an application, supported by an adequate, written clinical motivation for the continuation of medicine not listed on the formulary, or a substitution of the formulary medicine (in cases where the formulary drug would be ineffective or harmful).
- The formulary medicine is not available from the Designated Service Provider appointed by the Scheme or would not be provided without unreasonable delay.
Oncology Programme
Retail Medical Scheme members and their dependants, who have been diagnosed with cancer, can register on the Oncology Programme. Patients get support and access to reliable information on cancer and what steps a patient can take to manage and live with the disease. To register, call 0860 101 252.
We work with you and your doctor to ensure the most clinically appropriate and cost-effective treatment plan. We pay most claims related to treating cancer from the Core Benefit, and only some claims from the day-to-day benefits.
The Oncology Programme covers the first R200 000 of your approved cancer treatment in full, over a 12-month cycle. Once your treatment costs go over this amount, the Scheme will pay 80% of the Scheme Rate for all further treatment and you will need to pay the balance from your own pocket. This amount could be more than the 20% deductible if your treatment cost is higher than the Scheme Rate.
PET scans
If we have approved your scan and you have it done in our PET scan network we will pay your claim as follows:
If you have not reached the Oncology threshold
The Scheme will pay up to the agreed rate for your cancer treatment.
If you have reached the Oncology threshold
The Scheme will pay 80% of the Scheme Rate and you must pay the shortfall. This amount could be more than 20% if your healthcare provider charges higher than the Scheme Rate.
If we have approved your scan and you have it done outside of our PET scan network we will pay your claim as follows:
If you have not reached the Oncology threshold
You must pay a portion of the scan cost from your pocket
If you have reached the Oncology threshold
The Scheme pays the claims at 80% of the Scheme Rate. You must therefore pay the claims shortfalls as well as a the applicable co-payment.
You have access to local and international bone marrow searches and stem cell transplants
This benefit is unlimited at the Scheme's DSP, subject to registration on the Oncology Programme. A limit of R1 million applies if the Scheme's DSP is not used.
Advanced Illness Benefit
The Advanced Illness Benefit provides funding for the care of patients with end-of-life stage illnesses and covers, amongst others, the following out-of-hospital services: GP and Specialist consultations, including home based care; specialist Hospice nursing care; general nursing care obtained from a Discovery HomeCare provider, where available; oxygen, pain management, wound care, counseling, pathology and medicine (per defined baskets) and appropriate feeds.
Documents for your Cancer benefit
HIV Treatment
We have a special HIVCare Programme and it is very important that you contact us before you have treatment for HIV or AIDS. Our HIVCare healthcare team respects your right to privacy and will deal with you in complete confidentiality.
The HIVCare team will only speak to you as the patient, or your treating doctor, about any HIV-related query.
You need to register on the HIVCare Programme to access these benefits. Call us on 0860 101 252, or send an email to HIV_Diseasemanagement@retailmedicalscheme.co.za to register. If your condition meets our requirements (benefit entry criteria) for cover, you will have cover for antiretroviral medicine. This includes supportive medicine and medicine for prevention of mother-to-child transmission, treatment of sexually transmitted infections and HIV-related (or AIDS-defining) infections that are on our HIV medicine list (formulary).