Who funds baby formula? The short answer is not your medical aid!

Reading time: 8 min

When you have a hospital birth, you expect that your meals will be included in the (often astronomical) hospital bill you’ll receive. The hospital bill usually covers your theatre time, bed, nursing care, and food, and you will be individually billed for each “consumable” you use during medical care.

Consumables are medical items such as dressings, and not food and drinks. But on that subject, you will not generally receive a separate line item on your invoice detailing the meals you ate during your stay.

You may ask for or even be offered a top-up formula feed during your hospital stay with your newborn if they seem particularly eager to feed, or if you badly need to rest. However, it’s unlikely you’ll be charged for it as an itemised line on your hospital bill.

We set out to find out which medical aid schemes cover infant formula and which brands, and if your baby receives a formula feed while you’re both in hospital, does this even reflect on your bill?

Mediclinic and Life hospital representatives were unwilling to be quoted or drawn on the matter. Because of the government’s outspoken pro-breastfeeding policy, obtaining official comment from private hospitals on any matters regarding to the giving or sale of formula in hospitals is difficult, because hospitals may fear that their baby-friendly status is in jeopardy if they admit to handing out top-up formula to newborns – a practice that is discouraged in order to increase the chances of successful breastfeeding.

State hospitals’ PR departments did not return phone calls or emails on this subject, so there’s no official word on who funds formula feeds in state hospitals if and when these are provided prescription-free by nurses.

It was time to turn our attention to the medical schemes. A January 2019 feature in Business Tech helpfully listed the biggest medical schemes in the country, starting with Discovery Health with a 2.8-million-strong beneficiaries group and 31% market share. The Government Employees Medical Scheme (GEMS) is the second-biggest, but it’s a closed scheme. Bonitas is the second-biggest open scheme, with 15% market share, followed by police medical scheme Polmed (another closed scheme). Momentum Health, BestMed and MediHelp round out the biggest open schemes list, and BankMed slips in as the third-biggest closed scheme.

We asked them:

  • Do you cover the cost of formula in and out of hospital? Do you cover the services of a lactation specialist? If not, why not?
  • If you cover an out-of-hospital (OOH) lactation consult, why would you not cover OOH formula provision?
  • Do you cover the use of infant formula if there is a motivation for its use from the doctor, e.g. for reflux?
  • Which brands do you cover?

Discovery Health

Discovery’s head of clinical policy Dr Noluthando Nematswerani said the scheme “covers lactation consultations provided by a registered nurse or breastfeeding specialist from the Scheme’s Maternity Benefit to promote and encourage healthy breastfeeding. The purchase of patented foods, including baby food, is excluded from cover from the Scheme. Discovery does, however, fund nutritional feeds or formula through its HIV Care Programme for babies born to HIV-positive mothers up to six months of age.” There is no provision for cover for other conditions such as reflux.

The key word is “patented”.

“Patented foods, including baby food, does not meet the definition of a relevant healthcare service or product and is only covered in exceptional medically appropriate situations (such as the HIV example)”, explains Dr Nematswerani.

The formulas covered by Discovery are all in powder form (rather than ready-to-feed) and include: Wyeth’s, Infacare 1, Infacare Soya 1 by Aspen, and Melegi nurture acidified infant formula (also manufactured by Aspen), as well as Lactogen 1 from Nestlé.

The Prevention of Mother To Child Transmission Benefit is in line with Prescribed Minimum Benefit regulations. The formulary, therefore, comprises of clinically appropriate and preferentially priced items only. All requests for non-formulary formula feeds will be considered on a clinical appeals basis.

BestMed

Bestmed’s clinical wellness case manager, Christine Schotkamp also weighed in with an answer: “The regular formulas such as Nan and Wyeth S26 during hospitalisation are not charged by the hospital as meals are included in the fee. If the hospital does charge for it, it will not be funded by the scheme and the hospital must write it off.”

On the subject of lactation consultants, she advises: “A lactation specialist is not funded during hospitalisation due to the fact that nurses in the maternity wards are trained to help new moms with bottle- and breastfeeding and provide information regarding feedings. In the event that a lactation specialist is requested by the patient, the member will be liable for the cost thereof. However, if the hospital provides this service, it is their responsibility to pay the account.”

Out of hospital, the following limits apply to BestMed members:

  • The funding of formula is not restricted to babies born to HIV+ mothers, but the child must be younger than two.
  • For Nespray, a maximum of three 1.8kg refills per beneficiary in a year will apply in addition to the infant formulas.
  • There are additional restrictions according to the plan selected: Beat2, Beat2 Network, Beat3, Beat3 Network and Pace4 will pay from available savings; Pace1, Pace2 and Pace3 will pay from available vested savings, and Beat1, Beat1 Network, Pulse1 and Pulse2 will reject.

Medihelp

Vanessa Goosen from Medihelp explained her scheme’s position: “Most medical aids do not cover any patented nutritional supplements, as nutrition is not considered a medical intervention, neither during hospitalisation or as part of day-to-day cover. The philosophy is basically that we don’t cover the cost of food and list it as an exclusion in terms of the rules of the scheme.

“If your baby receives a formula feed while you’re both in hospital, does this even reflect on your bill?”

In Medihelp’s case, the registered rules state the following: “Substances not registered by the South African Health Products Regulatory Authority (SAHPRA). This excludes medicine items exempted from section 21 of the Medicines and Related Substances Control Act 101 of 1965, as amended … [including] food substitutes, food supplements and patent food, including baby food.”

“Likewise, Medihelp does not cover the services of a lactation specialist, while naturally the professional nursing services (subject to pre-authorisation) rendered during confinement in hospital (during which time breastfeeding guidance is provided) or during home delivery are covered. Any food supplement or formula is, however, not covered.”

Medihelp’s Nadine Koen added, “When the mother is admitted as a patient, her hospital authorisation includes her accommodation, which comprises her use of hospital facilities, as well as her nutrition. Formula milk is excluded from benefits in all instances and will be reported as such on the member’s claims statement with a relevant rejection message in the event that the hospital claims this from the scheme.”

Health Squared Medical Scheme also weighed in with comment. The scheme’s principal officer, David Smith, said, “The cost of in-hospital lactation consultations is included in the ward fees; however, out-of-hospital lactation specialists are not covered. While in-hospital formula is also covered as part of the ward fees where indicated, out-of-hospital formula is a scheme exclusion, and is therefore for the member’s expense. Exclusive breastfeeding has numerous documented health benefits for both baby and mother, and is therefore encouraged by Health Squared wherever possible.”

Momentum

Executive Head: Marketing and Distribution for Momentum Health, Damian McHugh says, “We do pay for formula in hospital if clinically necessary. As an example, we would cover it if there is malabsorption, or if a mom is HIV positive. If there isn’t a medical reason the member can utilise the Healthsaver account we make available, which members can use for any health-related cost a scheme may not cover.”

He continues, “We do believe in member choice and flexibility and hence offer solutions that try and cover as much of that choice as possible. We also know that new moms have a lot of decisions to make after the joy of having a baby. We do pay for lactation consults for moms as well and that is covered from risk benefits to try help the mom with breastfeeding choices, too.”

The other medial schemes polled for this article did not respond to requests for comment.

Disclaimer: This is not a sponsored post and is based on personal experience and personal brand preference of the content author. BabyYumYum reserves the right to its opinions and fully supports the notion of promotion that breast is best in line with the World Health Organisation (WHO) infant feeding guidelines. Breast milk is the best food for infants. Good maternal nutrition is essential to prepare and maintain breastfeeding. If breastfeeding is not applied, an infant formula may be used according to the advice of health professionals. Preparation and storage of any infant formula should be performed as directed on the tin in order not to pose any health hazards.