Medical Scheme Amendments Cause Unease

September 6, 2015

The Health Department is working on an amendment to a section of the Medical Schemes Act. This could mean a win-win medical scheme amendments for both subscribers and medical aid schemes.

If enforced, these amendments could mean that members won’t need to carry a co-pay whenever they go for treatment. Medical aid providers on the other hand will be able to negotiate for a tariff for prescribed minimum benefits (PMBs). And that will not require subscribers to have a co-payment. They also won’t need to pay for treatment of PMBs in full. Rather the tariff agreed in 2006 will apply.

Brilliant as this sounds, there are concerns that the move will result in a number of obstacles. It appears that healthcare providers are not part of the process despite their critical role in its implementation.

However, the attempt by the Department of Health to regulate tariffs could hit a snag. The government was going to withhold the amendment until completion of the Competition Commission inquiry into healthcare costs in South Africa. This investigation was expected to lead to a regulated tariff that all parties would be comfortable with.

Genesis Opposes New Medical Scheme Amendments

There is a case in court lodged by Genesis opposing the government’s proposed medical scheme amendments and it was thought that the Department of Health would await the verdict on this before publishing their amendments. The medical aid scheme argued that these amendments went beyond the confines of the law. By contrast, the Board of Healthcare Funders (BHF) are happy with the new amendment. It is in essence what they had attempted to achieve with an earlier court case.

Medical Scheme AmendmentsMedical schemes are largely also eager for the new amendment as it will give them the protection they required against healthcare providers who charged exorbitantly for treatment of PMBs. However, it is still not clear whether these providers will have to limit their charges to the proposed tariff. Or if they will still be free to charge what they want.

Future unsure

Subscribers to schemes are therefore still unsure. They don’t know if they will have to foot the excess if the healthcare provider does not recognise the tariff for PMB treatment. If there is a mutually agreed rate between the scheme and the provider, the member won’t have to pay for such excesses. And this is the reason their input was required in the drafting of the amendments.

All in all members of schemes can expect to see reduced occurrences of excess charges for PMBs by their schemes. But in the end they will still have to take up gap cover to cater for shortfalls between their scheme’s rate and the cost of healthcare. In fact the medical schemes amendments to regulation 8 which the Health Department is proposing will only make gap insurance that much more important. It will also be increasingly important for potential medical scheme members to seek the counsel of a healthcare advisor before taking up a policy. This will ensure they are fully aware of the cost of treatment vis-à-vis the tariff of their scheme.


All info was correct at time of publishing