National Health Insurance
Minimum Benefits for HIV, AIDS and TB.
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The changing benefits provided for HIV/AIDS as part of Prescribed Minimum Benefits (PMBs) in medical schemes are a mirror image of the changing benefits provided in the public sector for the disease. It is one of the clearest examples where the public and private sectors provide the same defined minimum package of care. While the private sector disease management companies and AIDS activists argued strongly for all medical schemes to include treatment for HIV, it was not until benefits were provided in the public sector that they became mandatory for medical schemes as well. From 1 January 2005 medical schemes have been required to provide the following package of minimum benefits for HIV/AIDS:
- HIV voluntary counselling and testing;
- Co-trimoxazole as preventive therapy;
- Screening and preventive therapy for TB;
- Diagnosis and treatment of STIs;
- Pain management in palliative care;
- Treatment of opportunistic infections;
- Prevention of mother-to-child transmission of HIV;
- Post-exposure prophylaxis following occupational exposure or sexual assault; and
- Medical management and medication, including the provision of antiretroviral therapy and ongoing monitoring for medicine effectiveness and safety, to the extent provided for in the national guidelines applicable in the public sector.
Dr Leon Regensberg made a substantial submission on the minimum package for HIV/AIDS for the 2008 review of Prescribed Minimum Benefits. He said: “While the existing prescribed minimum benefits for HIV/AIDS provide scope for reasonable cover, there are a number of practical problems that have been identified which may prejudice both schemes and members. In particular, with the exception of antiretroviral therapy, the existing regulations do not stipulate or make provision for clear treatment guidelines, clinical protocols or exclusions. This is particularly important in respect of treatment for opportunistic infections.”
He provided evidence of practical problems and proposed solutions for a number of concerns in the clinical management of HIV/AIDS. These included recommendations on Hepatitis B screening, diagnosis and treatment of sexually transmitted infections, screenin.g and preventive therapy for TB and improvements to the payment of voluntary counselling and testing for HIV. He argued that: “No waiting periods or exclusions should apply to HIV under any circumstances. [These are] in neither the scheme’s nor the beneficiary’s interest both from a financial and clinical perspective. For example, any exclusion on pregnancy should not extend to MTCTP.”
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