Special needs children: Will your medical aid pay?

Children with special needs and various developmental conditions are not always catered for in mainstream activities and events, such as going to the movies or the theatre. Moneybags journalist Jessica Anne Wood looks at what medical costs medical aids will cover for children with special needs.

Liziwe Nkonyana, executive of communications and member affairs at GEMS (Government Employees Medical Scheme), highlights: “Medical schemes provide cover for healthcare services within the scope of the regulated healthcare funding industry. In other words, medical schemes assist in covering the costs for those services deemed medically necessary and clinically appropriate. A special needs child does not constitute a medical condition per se, however, a special needs child may be afflicted with a medical condition and/or require surgical procedures related to the disability, which does fall within the scope of medical scheme cover. Other needs outside of the clinical component, for example educational aids, cosmetic surgery, and exercise programmes, will not be covered by the medical scheme. There is no ‘special needs child’ programme managed as a separate programme.”

As such, conditions such as Costello Syndrome, Down Syndrome, Autism, hearing loss, deafness and learning disabilities would not be covered by medical aid schemes under prescribed minimum benefits (PMBs), as these diseases/conditions do not have fixed treatments. However, other conditions that may be a result of or related to these types of conditions/diseases may be covered if they are covered under the PMBs.

“This is dependent on the patient specifics, severity of the conditions resulting from the disability and other co-morbidities of the patient. Therefore each patient seeking cover for healthcare services is evaluated as an individual, although the scheme rules, managed care and claims rules remain applicable. The disabilities mentioned above to not fall within the definition of PMBs. The scheme allocation of benefits is aligned to the relevant Acts that govern medical schemes,” explains Nkonyana.

However, Nkonyana points out that certain aspects of these disabilities, for example epilepsy, can be considered PMBs and as such, will be subject to relevant managed care rules. “Therefore, patients will have access to care for the co-existing PMB conditions in line with PMB entitlements.”

Dr Noluthando Nematswerani, head of the Discovery Health Clinical Policy Unit, adds: “Bipolar Mood Disorder is a PMB condition and one of the only two mental health conditions (the second is Schizophrenia) listed on the Chronic Disease List (CDL). This condition is covered across all plan types offered by the Discovery Health Medical Scheme from the Chronic Illness Benefit (CIB).”

Do medical schemes cover disabilities?

The simple answer is ‘No’. However, it is not quite that black and white. Disabilities are not covered by medical schemes as they are not, per se, clinical conditions.

Anton Engelbrecht, strategic consultant at Alexander Forbes Health, agrees, adding that the benefits available by the medical scheme and options chosen by the main member will apply. “The person with a disability can be the main member or can be a dependent on the spouse/partner or parents’ medical scheme and the special needs children will normally be a dependent on the parent’s medical aid.”

It’s key to compare medical schemes and sign up to the product that offers the best cover for your special needs child and his or her particular disability. Various medical schemes offer a number of services for care related to disabilities, such as GPs, physiotherapists, occupational therapists, psychologists, dietitians and some would even pay for a wheelchair if you meet the requirements. The extent of services available to a person and the expenses covered will be dependent on the medical scheme they belong to, as well as the option that they choose within the medical scheme.

Engelbrecht emphasises: “It is important to do a proper needs and benefit analysis in choosing the best scheme and best option. For example for a person needing assistance devices or rehabilitation benefits during a year would choose an option that provides sufficient benefits for external appliances like wheelchairs etc. The challenge is that each option provides different levels of benefits within a medical schemes well as the medical schemes provide different levels of benefits.

“What makes this even more complex is that there are a wide variety of medical diagnosis that results in special needs children like Down Syndrome or Spina Bifida just to name a few. The rehabilitation and assistive devices and treatment plan are different and would require a detailed analysis of needs for treatment and choice of medical scheme and the best option.

“In addition to the medical aid benefits there are also special tax arrangements allowed by SARS for both people/children with disabilities,” added Engelbrecht.

The cost of care

Unfortunately it is not possible to give definitive figures when it comes to the cost of care for a special needs child. Nkonyana explains that the extent and severity of the disability, and the change over time is based on the specific patient and may differ significantly from patient to patient.

To give a basic guideline as to the cost of caring for a special needs child, the Little Eden Society for the Care of Persons with Mental Handicap, has 300 residents, both children and adults, with profound intellectual disability. According to Nichollette Muthige, public relations and communications officer, it costs R11, 000 per month per child for Little Eden to care for its residents in terms of medication, therapy and other needs.

“Members are encouraged to familiarise themselves with the Scheme benefits in the benefit guides and the specific relevant processes to follow to access these benefits. Access to care and treatments, including requests for appliances, must be medically necessary to be covered and not related to social and education aspects of the condition,” says Nkonyana.

As for State help, there are grants available, which include disability grants, but these are not enough. Little Eden’s organisational profile for 2016 shows how it aims to become less dependent on government subsidies. It notes that of its 300 residents, 238 were previously abandoned or come from “indigent families who are unable to support them financially or otherwise.”

Due to this lack of family financial support for the residents, Little Eden is dependent on government funding, donations and fund raising to help cover the care costs for its residents. Of the R11, 000 per month required to care for each resident at Little Eden, R3 413 per resident comes from the Gauteng Provincial Government Department of Health, which represents 31% of this cost. A few of the residents also receive a disability grant of R1, 500 per month. The shortfall in the cost is funded through a variety of other means.

State hospitals for those who struggle financially or are not signed up to a private medical scheme can be accessed. The payment for State hospital care differs according to a number of factors. The Western Cape Department of Health explains: “Patients treated in government hospitals are charged according to a tariff called the Uniform Patient Fee Schedule (UPFS), which sets a tariff according to: The level of hospital providing the treatment; the category of medical staff providing the treatment; the income of the patient.

“Only full-paying patients are charged the full UPFS fee. Patients who receive social pensions or who are formally unemployed can get almost all hospital health services free of charge. Other patients with low incomes are partially subsidised. Those who have an income of more than R72 000 for a single person per year (or R100 000 income per family per year) pay the full-paying UPFS fee.”

When it comes to hospitalisation and care for mental health issues, the fee structure works in two ways. According to the South African Government’s website, “the cost for the service depends on two conditions. Where a patient is admitted involuntarily, that is, the person is so sick that they need medical attention without their consent, the service is free.

“Where a patient voluntarily consents and requests the service, they are liable for payment in terms of the Uniform Patient Fees Schedule.”

South Africa is due to introduce the NHI over the next 10 years or so, which is set to help the poor even more. A White Paper on the NHI is currently open for public comment. During the second phase of implementation, according to the White Paper, “vulnerable groups such as children, orphans, the aged, adolescents, and people with disabilities, women and rural communities will be prioritised.”