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 means that medical aid basic benefits are threatened.

According to health economist, Prof Alex van den Heever, current chair of Social Security Systems Administration and Management Studies at Witwatersrand University, if Government changes the law, it will be protecting medical “big business” at the expense of the sick and vulnerable in our society. He is adamant that if the DoH is successful in changing the legislation, it will have abdicated (or abandoned) its responsibility in terms of protecting members of medical aid schemes.

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. 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.

This particular clause in the legislation has been the subject of two court cases. It protects members of medical aid schemes, including diabetics, who 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 (as a whole) negotiating with pharmaceutical societies to drop their prices of relevant drugs. If the legislation is changed, this would remove any incentive for medical schemes to try and negotiate better prices with those companies that supply medical services, he maintains. 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 argued that benefits should not be paid in full (regardless of cost) in situations where there aren’t any tariffs that limit the amounts doctors are able to charge. The BOHF is one of the bodies that have lobbied Government and its DoH to review and possibly change the legislation.