Surgeries NOT covered by medical aid

As some consumers are all too aware, certain surgeries are not covered by medical aid schemes because they are considered cosmetic rather than functional. Cosmetic surgeries focus on a patient’s aesthetics, while functional surgeries improve health. However, a handful of surgeries that appear to be cosmetic, are in fact also functional. 

In these cases, how do medical aid schemes distinguish between the two?

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Drawing the line: cosmetic vs. functional surgery

The Council for Medical Schemes is a statutory body that provides regulatory supervision of medical schemes.

Ms Mmatsie Mpshane, acting general manager of stakeholder relations at the Council for Medical Schemes, points out that the line between cosmetic and functional surgery is not as blurred as some may think.

“In these cases, the provider would normally write a detailed motivation to the scheme, which would be considered by the medical advisor of the scheme, and a funding decision will be taken,” says Mpshane. 

“This motivation, together with the outcome of the assessment, and the scheme’s protocols, is the basis on which a funding decision is taken,” she says.

As an example, Mpshane points out that breast reconstruction surgery can form part of the management of breast cancer, for both affected and unaffected breasts. Surgical reconstruction of the unaffected breast may therefore be covered, depending on the clinical circumstance.  

“Due to the high costs that are often attached to these procedures, if cosmetic surgery was made mandatory for schemes to cover, it would be unsustainable for the schemes,” she explains. 

What are Prescribed Minimum Benefits?  

According to Mpshane, medical schemes are only compelled to cover conditions that fall under the Prescribed Minimum Benefits (PMB) designation, regardless of the member’s scheme or option. This is, however, subject to the use of designated service providers, evidence-based and cost-effective clinical protocols, and lists of medicines as supplied by approved providers.

“PMBs, which are mandatory for all schemes, are aimed at saving and prolonging a patient’s life. In this regard, reconstructive surgeries that are linked to the PMBs are covered,” says Mpshane.

“Cosmetic surgical procedures that are not listed on, or linkable to, the medical conditions covered by the PMBs, or the chronic disease list, or which do not qualify as an emergency medical condition as defined by the Medical Schemes Act (131 of 199), cannot be made mandatory for schemes to cover,” she explains.

Three examples of surgery - the Council for Medical Schemes

In order to understand this, we had a look at three different surgeries that are often excluded from medical aids: breast augmentation, gastric bypass, and gender reassignment surgery.

Mpshane maintains that breast augmentation and gender reassignment surgeries are not listed as PMB’s, while gastric bypass surgery may or may not fall under the PMB list, depending on the reason for the surgery.

“Therefore, schemes can cover them based on their specific rules, applicable to the member’s scheme option,” she says.

In other words, medical schemes are not compelled to cover these surgeries, but they may choose to cover them.

Three examples of surgery – two medical aid schemes 

Discovery Medical Health Scheme

Dr Noluthando Nematswerani, head of the Centre for Clinical Excellence at Discovery Health, explains that the Discovery Medical Health Scheme (DMHS) does not fund breast augmentation surgery if it is requested for purely cosmetic reasons.

However, DMHS does provide funding for breast reduction surgery under the following circumstances:

• If you are on the Executive plan and Comprehensive plan, and you have received a diagnosis of gigantomastia, you will be covered for this surgery, subject to a limit of R50,000. Clinical entry criteria apply.
• DMHS also funds breast reconstruction surgery for members with breast cancer post-mastectomy across all plan types.
• Breast reconstruction surgery for non-oncology cases is funded on a discretionary basis from the Reconstructive Surgery Benefit, subject to a R50,000 per-member benefit limit. This is only available to those on Executive or Comprehensive plans.

Nematswerani notes that DMHS funds gastric bypass surgery for members on Executive and Comprehensive plans, from the Specialised Medicine and Technology benefit. However, a 20% co-payment with an overall limit of R200,000 per person per annum applies.

In terms of gender reassignment surgery, Nematswerani explains that this is a general scheme exclusion.

“However, DMHS does provide funding for gender reassignment surgery as part of a pilot programme for members on Executive and Comprehensive plans with a diagnosis of gender dysphoria,” says Nematswerani.

To qualify, members must be 18 years or older, and have belonged to the specified plans for a minimum period of at least three years. A co-payment of 20% is applicable with an overall limit of R200,000.

Fedhealth

According to Jeremy Yatt, principal officer at Fedhealth, all three of the above-mentioned surgeries (breast augmentation, gastric bypass, and gender reassignment surgery) are currently exclusions and will not be funded by Fedhealth. 

However, he adds, “Although these procedures are generally regarded as cosmetic surgery, the scheme evaluates each request individually.”

He continues, “The scheme then determines whether it is purely a cosmetic request or if there is a functional reason for the request, which may prevent downstream costs for the scheme, and improve the health and quality of life of the member.”

“If the reason is the latter, then there is more justification to fund this,” he concludes.

An alternative to medical aid

If required, breast augmentation surgery can be done at a day hospital for 25% less than an overnight hospital.

“Day hospitals, as the name suggests, are used solely for surgical procedures that do not require overnight hospital stays,” says Bibi Goss-Ross, COO of Advanced Health Group.

“Because of this, the cost of surgeries performed in these facilities is significantly lower than those done in traditional hospitals. The quality of healthcare is excellent thanks to the fact that day hospitals house state-of-the-art theatres and attract some of the top surgeons,” Goss-Ross points out.

Gastric bypass and gender reassignment surgery are too risky to be performed in day hospitals.

The figures below, supplied by Lee Callakoppen, principal officer at Bonitas Medical Fund, illustrate the savings available across several common surgeries performed at both day hospitals and overnight, or acute, hospitals.