Understanding Juvenile Idiopathic Arthritis and Its Coverage Under Medical Schemes in South Africa

Juvenile Idiopathic Arthritis (JIA) is an autoimmune disease where the body’s immune system mistakenly attacks its own healthy cells and tissues, leading to inflammation in the joint membrane or the synovial membrane. This condition is the most prevalent type of arthritis in children under the age of 16.

JIA is included in the Chronic Disease List (CDL) of the Prescribed Minimum Benefit (PMB) regulations under Rheumatoid Arthritis in South Africa. This means that medical schemes are obligated to fully fund the diagnosis, treatment, and care costs of this condition, according to the Council for Medical Schemes (CMS). However, the treatment guidelines for JIA reference the algorithm for Rheumatoid Arthritis for adults, which can differ significantly from the needs of children with JIA.

With JIA, an alternative paediatric clinical management protocol must be included within this benefit if it is supported by evidence-based medicine, considering cost-effectiveness and affordability. Sources to use include the American Academy of Orthopaedic Surgeons, Arthritis Kids South Africa, Johns Hopkins Medicine, Mayo Clinic, Medline Plus and National Institutes of Health.

Medical schemes may use medicine formularies – a list of specific medicine for the treatment of the condition. Therefore, it’s crucial to check with the medical scheme which medicines are included in the medicine formularies to avoid a co-payment on the chronic medication. If a member or beneficiary of a medical scheme chooses to use medicines not on the formulary, a co-payment on the treatment may be applied. This update from the CMS does not include specific information regarding the use of biologics in JIA.

Medical schemes are also allowed to put in place baskets of care that allow for a specific number of consultations, blood tests and other tests to monitor the condition. However, when care outside of the normal basket is required, the medical scheme cannot completely refuse to fund it. The treating doctor should send a letter of motivation to the medical scheme indicating the required care and the reasons. If clinically appropriate, the medical scheme must fund it as PMB.