Medical Aid for Chronic Conditions: Managing Your Health

Receiving a diagnosis of a chronic condition from a doctor or nurse can be shocking and surprising. The initial response is often denial, followed by reassurance that your medical aid covers chronic medicine. But does it?

The biggest disappointment comes when medical aids reject an application for chronic medication, and the client's immediate response is, "But my doctor said I need to take this medication forever because it's chronic."

In South Africa, medical aids are required to cover certain chronic conditions and medication, but only specific conditions are included in the Chronic Disease List (CDL). This list ensures that all medical aid schemes fund the diagnosis, medical management, and medication for 26 specified chronic conditions.

These conditions are covered in full if services are rendered according to the scheme's benefits, treatment plans, and protocols. Medical funds can expand this list, adding extra chronic conditions and medication. However, even if a doctor diagnoses a condition and prescribes chronic medication, it may not be one of the listed conditions covered by medical aids.

Additionally, medical aids may not cover medication as chronic if the client's plan does not provide coverage. Some plans allow clients to opt-out of chronic benefits, choosing instead to access chronic care at government facilities, which can result in premium savings.

In summary, belonging to a medical aid does not guarantee coverage for chronic conditions or medication. Coverage depends on whether the condition is a listed CDL, the medication is on the formulary list, and the plan offers coverage for the diagnosed condition.

To ensure you are on the correct medical aid, please contact an Optimum Adviser for expert advice.