A child with special needs might require specialised care that your medical scheme may not pay for.
We ask the experts how to select the appropriate medical aid for a youngster needing specific support.
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What are “special needs”?
Children with special needs have physical, behavioural, or intellectual difficulties that require a wide range of therapies, accommodations, or services.
Conditions and illnesses such as autism, cerebral palsy, Down's syndrome, dyslexia, dyspraxia, blindness, deafness, attention deficit hyperactivity disorder (ADHD), cystic fibrosis, and many more, fall within the broad spectrum of special needs health issues.
Do medical schemes offer a special needs benefit?
A child with special needs is not considered different to any other scheme member when it comes to medical aid coverage, says Dr Justine Greeff, medical advisor: hospital benefit management at Bestmed Medical Scheme.
“There’s no special needs benefit. Conditions not covered under the prescribed minimum benefits are covered by savings or day-to-day benefits, depending on the availability of funds,” she explains.
“Parents must ensure that their chosen benefit option covers all their healthcare needs. These needs may include medication, hospital-based care, or other services.”
Karin Haggard, marketing manager at Optivest Health Services, says there are no standalone diagnostic criteria relating to special needs that allow for specific coverage by a medical scheme. However, a specific, medically diagnosed impairment is generally accepted as a special need.
“Medical schemes cover chronic conditions, GP and specialist visits, X-rays, and blood tests, but they also offer benefits for various conditions,” Haggard notes.
How to compare options
Tarri-Dee Botes, research manager at MedicalAid.com, advises considering your family’s specific needs when selecting a medical scheme.
“Look at coverage for paediatric care, vaccinations, and potential pre-existing conditions. Ensure your network has paediatric specialists, and assess the overall cost versus benefits. Also, check that the hospital plan or savings account covers the entire year’s expenses,” Botes recommends.
“Gap cover is a valuable addition to your medical aid as it pays out the difference between what your medical aid pays and the actual healthcare costs, depending on your gap cover option,” she adds.
“If your child needs specialised treatments, or you face high out-of-pocket expenses, gap cover ensures that financial constraints don’t compromise your child’s healthcare.”
Botes offers some advice on good medical schemes for three common special needs conditions affecting children, as follows.
Autism: Bestmed. Bestmed covers autism treatment on its Pace2, Pace3, and Pace4 options, even though the condition is not on the list of chronic diseases that South African schemes are legally required to cover.
To apply for the cover, the scheme requires a prescription from a paediatrician, neurologist, or child psychiatrist. Medicines are authorised based on a “formulary” – a predetermined list of covered medicines for which your scheme may reimburse you.
Down's syndrome: Discovery Health. The scheme’s Allied, Therapeutic and Psychology Extender Benefit gives members who meet the clinical entry criteria unlimited coverage for a list of services.
The benefit covers members with severe, complex conditions who require short- or long-term assistance from allied, therapeutic, or psychological healthcare professionals.
Your child’s condition must meet specific criteria and the appropriate clinical guidelines. The application must be completed by a physician, neurologist, or paediatrician, or you would need to supply a copy of genetic test results confirming the diagnosis.
ADHD: Fedhealth and Momentum. Fedhealth and Momentum offer chronic benefits for beneficiaries, including children, diagnosed with ADHD. These benefits are usually limited to the schemes’ more expensive top-tier plans.
Fedhealth covers ADHD (for children aged six to 18 years), depression, generalised anxiety disorder, and post-traumatic stress disorder, subject to an annual limit of R3,200 per family.
Momentum’s Incentive Option, subject to an annual limit of R12,400 per family, covers ADHD, among other conditions. For more day-to-day cover, members can also choose complementary products that allow them to save for medical expenses.
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