Amended Medical Aid Regulations

The Council for Medical Schemes (CMS) regulator has commented on the amendments to Regulation 8  with reference to prescribed minimum benefits (PMBs).

But what do these amended medical aid regulations mean for the medical aid member in South Africa?

In July 2015, health minister Aron Motsoaledi published draft regulations to the Act, proposing amendments to Regulation 8, laying out the prescribed minimum benefits medical aids are required to pay. The idea is to ensure that all registered healthcare providers subscribe to a regulated tariff.

No Co-Payments for Members

The Prescribed Minimum Benefits (PMBs) include nearly 300 serious health conditions, emergency conditions as well as chronic diseases. Medical Schemes have to pay in full and without any co-payment from members. These amendments to Regulation 8 have been brought about to offer maximum protection to medical aid members so that when they do face health care issues, they aren’t faced with a financial predicament.

Amended Medical Aid Regulations and PMBsThe Act, implemented by the CMS, was introduced to provide medical scheme members with access to quality care. The Medical Schemes have to ensure that their members receive uninterrupted treatment and care for PMB conditions, without co-payments. Medical Aids will manage costs through the appointment of designated service providers (DSPs). These service providers will provide services at a rate which has been negotiated.

The proposed amendment reads:

(i) in respect of any service rendered by a health care professional who is registered with the Health Professions Council of South Africa, medical schemes are liable for payment for services in accordance with the billing rules and the tariff codes of the 2006 NHRPL tariffs published by the Council….
(ii) schemes may discuss alternative fees with any provider of any relevant health service for which no co-payment is payable by a medical aid member
The idea is for medical aids to set up a benefit structure where they can identify suppliers that will benefit patients who go to them and that there won’t be any additional out of pocket payments to be made.

No Longer Forced to Pay Outrageously High Prices

The Southern African Board of Healthcare Funders has given the thumbs up for the new proposed amendments, as they believe it won’t only benefit the members, but medical aids as well. With these amendments, health care providers won’t have a blank cheque and medical aids won’t be allowed to be reckless with the money of medical aid members.

At the moment the fees that healthcare providers are charging for PMBs is unregulated which means these health care providers can simply charge whatever they like for their services. Medical aid members are pleased with this because it gives them the assurance that they are not being exploited with ridiculously high medical prices.

Medical aid members will no longer be out of pocket when it comes to PMBs. Not everyone holds this view however, and some feel that it is a step backward. They say that by raising the patient contribution for those medical procedures covered by medical aid, more South Africans are going to be forced to turn to the public health system.
Regulation 8 and the proposed amendments have got stakeholders for and against it, so it requires efforts and consideration from government to ensure fairness with the givers and the receivers in the medical aid industry.

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