FAQ

Medical Scheme Funding for hip and knee joint replacement procedures (FAQ)

1. What are benefit limits or prosthesis limits?
   Your Medical Scheme has established limits for hip or knee joint replacement that your Surgeon will use. These limits are known as “prosthesis” or “internal prosthesis” limits and are a limited Rand amount that your Medical Scheme will pay.

2. How do you confirm your available prosthesis limit?
   As soon as your surgeon has advised that you need to undergo hip or knee joint replacement surgery, you should contact the Hospital Preauthorisation Department at your Medical Scheme, obtain authorisation to perform the procedure and discuss possible dates for surgery, which will then be confirmed with the Medical Scheme. Any additional clinical information requested by the scheme will also be provided at this time.  The Hospital Preauthorisation Department at your Medical Scheme should confirm the Internal Prosthesis Limit available to you, as you will be liable for any costs in excess of the available limit.

3. What do you do if your available prosthesis limit is less than the cost of the prosthesis that your Surgeon wants to use?
   Your surgeon will select the most appropriate hip or knee replacement (prosthesis) for you, based on your age, how physically active you are and any other lifestyle considerations. If the cost of the prosthesis is higher than your available prosthesis limit, you can choose to pay the shortfall cost. 

4. What can you do if you cannot afford the prosthesis cost shortfall?
   Your Medical Scheme may in some cases, be able to provide special funding, known as “ex-gratia” funding. This is a discretionary pool of money to which all members of your Scheme potentially have access to and which therefore has to be motivated for. To find out if this special funding option is available to you, contact your Medical Scheme Client Services Department to discuss. They will also advise you on the correct procedure to be followed. Points to consider include: Does your scheme have a special form to be completed? If yes, ask for this to be faxed or e-mailed to you. Whether there is a scheme-specific form or not, you may be asked to provide:

• A motivation letter from your surgeon

• Evidence of financial necessity, and

• A cost quotation from the company who distributes the prosthesis in South Africa.

You will also need to find out what date the funding review meeting will be held, so that you can be sure you know how much additional funding will be made available to you before you finalise your surgery date. Remember also that you are important to your Medical Scheme; they want to retain you as their member. Take charge of this opportunity to negotiate with your scheme on this critical lifestyle decision. You may be able to “buy up” to a plan that your Medical Scheme offers, which provides for a higher prosthesis benefit during the course of the year. This will depend on the rules of your specific Medical Scheme. You may also consider delaying your procedure until your Medical Scheme allows you to change your plan.