Medical Scheme Amendments Cause Unease

The Health Department is working on an amendment to a section of the Medical Schemes Act which could mean a win-win for both subscribers and medical aid schemes. If they come into force, 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) that will not require subscribers to have a co-payment. They will also not be required to pay for treatment of PMBs in full, but according to the tariff agreed upon in 2006.

Brilliant as this sounds, there are concerns that the move will be faced with a number of obstacles. It appears that healthcare providers have been omitted from this process despite their critical role in its implementation. It is therefore feared that the attempt by the Department of Health to regulate tariffs will hit a snag. It was thought that the amendment would be withheld until the Competition Commission completed its inquiry into the cost of healthcare 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 amendment and it was thought that the Department of Health would await the verdict on this before publishing their amendments. The medical aid scheme had argued that these amendments went beyond the confines of the law.In contrast, the Board of Healthcare Funders (BHF) are happy with the new amendment which 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 be forced to limit their charges to the proposed tariff or if they will still be free to charge what they want.Subscribers to schemes are therefore unsure of whether they will be the ones to foot the excess if the healthcare provider does not recognise the tariff for PMB treatment. If there was a negotiated rate between the scheme and the provider, the member will be saved from paying 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 amendment 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.