Draft Medical Aid Regulations Could Mean Less Cover

South African patients’ rights groups are concerned that patients may be forced to cover the cost of certain treatments which are currently covered in full by their medical schemes. This follows the announcement of new draft regulations from the Department of Health recently concerning payment for PMBs (prescribed minimum benefits).

However, the director-general for the Health Department Dr. Anban Pillay tried to allay these fears, insisting that patients would not be required to pay for PMBs. Currently the Medical Schemes Act requires medical schemes to pay for conditions listed under the PMBs in full. Strokes, viral meningitis and certain types of cancer are some of the 270 conditions and chronic diseases that are covered under PMBs.

Draft Medical Aid RegulationsPillay says that the department’s aim in introducing the new rules was to try and ensure that patients don’t have to make additional payments on top of what their medical aid scheme pays out. This aim is to be achieved by helping the schemes “…identify suppliers of service and structure that benefit such that when the patients go to these suppliers there is no additional out of pocket payment that has to be made.”

However, the attorney for an NGO set up to protect the rights of medical scheme members, Section 27, reads mischief into the government’s new proposed legislation.

Instead of alleviating the financial burden on policyholders, UmunyanaRugege says the new amendments will erode what little cover they currently enjoy. The current position at least guarantees patients some degree of access to healthcare and this, he fears, may be taken away.

On their part, medical schemes side with the government and feel that the new regulations will give them better sustainability by helping mitigate the costs of funding treatment of PMBs.