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The short strokes of prescribed minimum benefits

admin — Tue, 13 Dec 2011 09:55:03 +0000

In this issue of CMScript, the e-newsletter dedicated to prescribed minimum benefits (PMBs), the Council for Medical Schemes discusses strokes and how they are covered by your medical scheme.

What is a stroke?
A stroke is also called a cerebrovascular accident (CVA) and occurs when blood supply to and/or inthe brain is disrupted, causing brain cells to die. Ischaemic strokes are characterised by insufficient supply of blood to the brain and hemorrhagic strokes are characterised by bleeding inside the brain.

What causes a stroke?
Blood flow to the brain can be compromised in various ways. A blocked artery can cause ischaemia (insufficient supplyof blood to an organ); a ruptured artery causes bleeding within the brain. Risk factors for a stroke are high blood pressure, diabetes mellitus, smoking, and high cholesterol.

“A stroke is always
an emergency
– and all
emergencies are
PMB conditions.”

What are the signs and symptoms of a stroke?
The symptoms of a stroke depend on which area of your brain has been affected. The most common signs of a stroke are the sudden onset of:
• numbness or weakness of the face, an arm or
leg, usually on one side of the body; sometimes
weakness in face muscles can cause drooling;
• loss of voluntary movement and/or sensation that
may be complete or partial;
• confusion;
• trouble speaking and/or understanding;
• trouble seeing with one or both eyes;
• trouble walking, dizziness, loss of balance or
coordination; and
• a severe headache with no known cause.

The symptoms may be permanent or last less than 24 hours, with full recovery. When symptoms last for less than 24 hours, the type of stroke is called a transient ischemic attack.

What is the diagnosis and treatment for a stroke?
A stroke is always an emergency. If someone suffers from a stroke, they must be rushed to the nearest emergency room because early treatment may reverse some signs of the stroke. Most diagnostic tests take place in an emergency room and may occur simultaneously. Normally a stroke is diagnosed from your medical history and a physical examination, but further tests are required to identify the cause of the stroke and extent of damage to the brain.

The following tests may be done to diagnose a stroke:
1. Electrocardiograph (ECG): To monitor the heart and detect any heart-related conditions that may cause a stroke, e.g. atrial fibrillation (a form of cardiac arrhythmia).
2. Computerised tomography (CT) scan: To image the part of the brain that may be damaged. To get even more information, your doctor may perform a CT scan with an angiogram. This simply means that a dye is added to your blood intravenously so the doctor can see your blood vessels better. Imaging of the brain also tells the doctor what sort of stroke you have suffered because treatment is different for each case.
3. Magnetic resonance imaging (MRI) scan: This test is normally done when a CT scan does not provide all the information your doctor needs.An MRI scan also images the part of the brain that may have been affected by insufficient blood supply.
4. Blood tests: Your doctor may perform a battery of blood tests, firstly to check how your blood is clotting and secondly to check if you are anaemic or have any other diseases such as liver disease. Blood tests may be repeated depending on your condition.
5. Chest X-rays: To check for an enlarged heart and exclude complications such as chest infections. How a stroke is treated depends on what its cause is. Treatment normally involves medical management (control of high blood pressure, support and ventilation,and medication to dissolve clots) and/or surgical intervention. Patients who have suffered a stroke may require both intensive care and supportive care; the latter may include bed bathing and feeding if the patient is paralysed as well. After treatment, the signs and symptoms of the stroke may be completely reversed or may result in permanent damage to the brain. Long-term care also includes intensive management of high blood pressure, diabetes and high cholesterol to try and prevent another stroke. Stroke patients must stop smoking and adopt a healthy lifestyle to prevent further strokes. Long-term care of stroke patients focuses on helping them regain strength, recover as many functions as possible, and return to independent living. Patients may require physiotherapy, occupational therapy and/or speech therapy.

What are the possible complications of a stroke?
Strokes may cause temporary or permanent disabilities. The severity of the disability depends on how long the brain had been deprived of blood and which part of the brain was affected. As with any brain injury, the success of treatment varies from one person to the next.

Complications of a stroke may include:
•• Paralysis or partial loss of muscle
movement
•• Difficulty talking and/or swallowing
•• Memory loss
•• Trouble understanding
•• General pain
•• Changes in behaviour and self-care

What your scheme must fund Prescribed minimum benefits or PMBs cover the diagnosis, treatment and care of strokes. Medical schemes must therefore fund the following (in full):
•• Diagnostic tests (as described above)
•• Medical treatment
•• Surgical procedures
•• Rehabilitation
•• Assistive devices such as wheelchairs and walking rings

A stroke is always an emergency and all emergencies are PMB conditions – conditions which your medical scheme must cover in full provided you make use of your scheme’s preferred or designated network of service providers. In an emergency situation you may not necessarily be able to reach a designated service provider (DSP) of your scheme;you can use a non-DSP for your emergency in that case.

Prescribed minimum benefits (PMBs) are the minimum level of diagnosis, treatment and care that your scheme must pay for from its risk pool and in full according to law. There are medical interventions over and above those prescribed for PMB conditions but your scheme may choose not to pay for them. PMBs include 270 serious health conditions, any emergency condition and 25 chronic diseases which can be found on our website by clicking on this link (www.medicalschemes.com/ medical_schemes_pmb/index.htm). A designated service provider (DSP) is a healthcare provider (e.g. doctor, pharmacist, hospital) that is your medical scheme’s first choice when you need treatment or care for a PMB condition. You can use a non-DSP voluntarily or involuntarily but be aware that if you choose to use a non-DSP, you may have to pay a portion of the bill as a co-payment. If your condition is an emergency like in the case of a stroke and the closest medical facility to you is a non-DSP, you can use the non-DSP and your scheme will still have to fund the treatment in full.

How prescribed minimum benefits help you manage diabetes

admin — Tue, 13 Dec 2011 09:43:21 +0000

What is diabetes mellitus?
When we eat, the food is broken down into materials that our bodies need to function properly. One of the substances into which food is broken down is the simple sugar glucose. Sugar is absorbed into the bloodstream and stimulates the pancreas to produce insulin. Insulin allows sugar to move from the blood into the cells where it is converted into energy.
Diabetes is a chronic disease where your blood sugar levels (blood glucose) are too high because the normal control mechanisms of your body fail.
There are two types of diabetes, namely type I and type II. The two types are actually two completely different diseases.
Diabetes type I occurs when your body does not produce adequate quantities of insulin. It typically starts in early childhood.
Diabetes type II occurs when your body does not make enough insulin or, even if adequate amounts of insulin are produced, the body fails to transport the glucose from the bloodstream into the body cells. Type II usually starts later in life.
The result of both is that the glucose stays in your blood and cannot be used as an energy source for normal cell functions.
Diabetes leads to serious complications and could even jeopardise your life. It may cause heart disease and strokes and damage the eyes, kidneys and nervous system. Blood sugar levels that are too high or too low can also cause you to fall into a coma.
Diabetes cannot be cured but it can be successfully managed.
Treating diabetes
The treatment of diabetes focuses on the control of blood sugar levels. Treatment involves all aspects of your lifestyle, especially diet and exercise, but most sufferers also use medicine management at some point.
People with diabetes mellitus type I almost always need insulin therapy but lifestyle management is still important. People with diabetes mellitus type II may be able to manage their disease with lifestyle changes but if blood sugar levels cannot be controlled this way, oral anti-hyperglycaemic drugs and even insulin therapy may be required. Treatment of other risk factors such as blood pressure and high cholesterol is extremely important.

PMB entitlement
Diabetes mellitus type I and type II are included on the prescribed minimum benefit (PMB) Chronic Diseases List. This means that your medical scheme must fund the diagnosis, treatment and care of your condition and it must do so from its risk pool and in full.
Your condition must be treated according to the algorithm in the PMB regulations. These algorithms are also available on the Council for Medical Schemes (CMS) website at the following links:

http://www.medicalschemes.com/files/Prescribed%20Minimum%20Benefits/DiabetesMellitus1_2.pdf

http://www.medicalschemes.com/files/Prescribed%20Minimum%20Benefits/DiabetesMellitus2_3.pdf

The disease management interventions that must be funded by the scheme include:
- Consultations with your treating provider (GP or specialist – if authorised by your scheme)
- Lifestyle modification interventions such as dietary and disease education
- Annual eye examination for retinopathy
- Annual comprehensive foot examination
- Pathology tests at 3-6 monthly intervals
- Disease identification card or disc
- Home glucose monitoring

It is important to remember that the scheme may still use managed care protocols which for instance allow only a specific number of consultations with your treating provider per year. These protocols must be supplied to you on request.
If there is a clinical reason or need for more benefits than those specified in the protocol the medical scheme may not refuse to fund these.
The Communications Unit would like to thank Ronelle Smit, Dr Nkuli Mlaba, Dr Selaelo Mametja and Dr Boshoff Steenekamp for making this edition of CMScript possible.

Frustrated

admin — Wed, 02 Nov 2011 09:08:20 +0000

GET GAP COVER NOW BEFORE YOU ARE FACED WITH A FINANCIAL SHORTFALL!

FACT: Most Medical Aids only pay 1/3rd of a specialist’s bill for in-hospital procedures. You will pay the balance unless you have Gap Cover.

HOW GAP COVER WORKS:

CompliMed has the following waiting periods and exclusions:

- 3-month general waiting period;
- 12-month condition specific exclusion;
- 12-month pregnancy/birth exclusion in the first year of the policy
- The policy will not pay out if the member is hospitalised for the treatment of depression, insanity/mental distress, or psychotic/psychoneurotic disorders;
- The policy has a permanent cancer exclusion for any member of the family that has been diagnosed or treated for cancer on the Cancer Treatment Enhancer Benefit.

Unmarried adult children that are fulltime students and are still on the Principle’s medical aid are covered to the age of 25, unless they are either mentally or physically incapacitated from maintaining themselves.

The maximum entry age to qualify for Gap Cover is age 70 next birthday.

What’s your experience of Get Gap Cover?

admin — Fri, 22 Oct 2010 17:46:12 +0000

During the last couple of years Get Gap Cover has assisted hundreds of clients in successfully lodging claims to cover their Medical Aid Shortfalls.

From small claims of R200 up to R7000, having Get Gap Cover has helped make medical expenses bearable.

We’d like to hear your opinion of our services and how we can assist you better by you posting your video, comment on our Facebook page or here on our site.

Thank you to all our loyal clients and we look forward to hearing your voice.

Life without Gap Cover

admin — Mon, 27 Sep 2010 11:45:07 +0000

Do you think you need Gap Cover?

Do you know what Gap Cover is?

Have you or any of your family been in a medical emergency where you’ve been told your medical aid doesn’t cover the procedure you need?

What do you think of the new suggested Medical Aid Price increase?

admin — Mon, 27 Sep 2010 10:59:14 +0000

Read more about Discovery Medical Aid Rate increase from the Mail and Guardian here.