Medical Aid Basic Benefits Threatened

The Department of Health (DoH) might change the legislation that currently forces medical aid schemes to pay the full amount for certain treatments regardless of fees charged by service providers. This represents a threat to medical aid basic benefits.

So we interviewed health economist, Prof Alex van den Heever.

He is current chair of Social Security Systems Administration and Management Studies at Wits.

And he said: if Government changes the law, it will be protecting medical “big business” at the expense of patients.

Furthermore, van den Heever says legislation does change, the DoH will have abdicated its responsibility to protect medical scheme members.

Medical Aid Basic Benefits Threatened Says Prof Alex van den HeeverThe legislation that could be changed by the DoH was introduced in 2004 in an endeavour to ensure that all members of medical aid schemes in South Africa received basic medical cover.

Importantly, this law requires that medical aid societies must pay the full costs for all life-threatening emergency treatments, as well as 26 chronic diseases and another 270 medical conditions.

Significantly, this particular clause in the legislation has been the subject of two court cases. And it protects members of medical aid schemes, including diabetics. Because these patients can easily use the normal medical aid cover for the medication they need in just six months.

Medical Aid Basic Benefits Currently Guaranteed

According to Van den Heever, the law as it stands has forced medical aid societies to pay for chronic medication. This, in turn, lead to medical aid societies negotiating with pharmaceutical societies to drop their prices.

So if the legislation changes, this would remove any incentive for medical schemes to negotiate better prices. Then patients who belong to medical aid schemes could be left with major co-payment bills for emergency treatment.

The Board of Healthcare Funders (BOHF), that represents medical aid schemes, has a different view. It argues that they should not pay benefits in situations without tariff guides.

Therefore, the BOHF is one of the bodies that have lobbied Government and its DoH to review and possibly change the legislation.