Which conditions are covered?

According to the Medical Schemes Act, medical schemes have to cover the costs related to the diagnosis, treatment and care of the following:

• Any emergency medical condition

  An emergency medical condition means the sudden onset of a health condition that requires immediate medical treatment and/or an operation. If the treatment is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death.

  In an emergency, it is not always possible to diagnose the condition before admitting the patient for treatment. However, if your doctor suspects that you suffer from a condition that is covered by PMBs, your medical scheme has to approve treatment. Schemes may request that the diagnosis be confirmed with supporting evidence within a reasonable period of time.

• A limited set of 270 medical conditions called Diagnosis and Treatment Pairs (DTPs)
  Diagnosis and Treatment Pairs (DTPs) are a limited set of ±270 medical conditions that qualify for PMB cover. A DTP links a specific diagnosis to a treatment and therefore broadly indicates how each of the approximately 270 PMB conditions should be treated. The treatment and care of PMB conditions should be based on healthcare that has proven to work best, taking affordability into consideration. Should there be a disagreement about the treatment of a specific case, the standards (also called practice and protocols) used in the public sector will be applied. Treatment and care for some of the conditions included in the DTPs may include chronic medication for HIV infection and menopausal management. In these cases, the public sector protocols will also apply to the chronic medication.
• 25 Chronic conditions that make up the Chronic Disease List (CDL)

  • The Chronic Disease List (CDL) specifies medication and treatment for the following 25 chronic conditions:

  • Addison's disease
  • Asthma
  • Bipolar mood disorder
  • Bronchiectasis
  • Cardiac failure
  • Cardiomyopathy disease
  • Chronic obstructive pulmonary disease
  • Chronic renal disease
  • Coronary artery disease
  • Crohn's disease
  • Diabetes insipidus
  • Diabetes mellitus types I and II
  • Dysrhythmias
  • Epilepsy
  • Glaucoma
  • Haemophilia
  • Hyperlipidaemia
  • Hypertension
  • Hypothyroidism
  • Multiple sclerosis
  • Parkinson's disease
  • Rheumatoid arthritis
  • Schizophrenia
  • Systemic lupus erythematosus
  • Ulcerative colitis

  To manage risk and ensure appropriate standards of healthcare, so-called treatment algorithms were developed for the CDL conditions. The algorithms, which have been published in the Government Gazette, can be regarded as benchmarks, or minimum standards, for treatment. This means that the treatment your medical scheme must provide may not be inferior to the algorithms. If you have one of the 25 listed chronic conditions, your medical scheme not only has to cover medication, but also doctors' consultations and tests related to your condition. Your scheme may use protocols, formularies and network healthcare providers to manage this benefit.