Medical Aid Schemes in South Africa
By Graeme David Coyne
Prescribed minimum benefits, your medical aid scheme and you; what are Prescribed Minimum Benefits?
There are over 300 medical conditions covered under the Prescribed Minimum Benefits (or PMBs) classification. These include: any emergency medical condition, a limited set of 270 defined medical conditions and 25 defined chronic conditions.
All PMBs are supposed to be paid in full by any medical aid scheme, from a member's risk benefits, but according to recent findings by the Council for Medical Schemes, this is not always the case.
The Council of Medical Schemes takes aim
At the start of 2010 the Council of Medical Schemes said it found that "91 percent of claims for PMBs are paid from scheme's risk benefits and the remainder are paid from members' medical savings accounts". This is in clear violation of the Medical Schemes Act, which prohibits medical aid schemes from paying for PMBs from a member's savings account.
In response to this development, the CMS, along with various role-players in the healthcare industry, has established a team to handle the issues surrounding compliance with prescribed minimum benefits. The team has also been tasked with developing a code of conduct relating to the implementation of PMBs. The code will govern all members of the healthcare industry.
Grey areas in the medical scheme industry
The Board of Healthcare Funders has approached the minister of health, Dr. Aaron Motsoaledi, to rewrite Regulation 8 of the Medical Schemes Act, claiming that it "had unintended consequences in that it has allowed an open-ended liability for schemes. The (CMS's) interpretation of this regulation is that schemes must pay for PMBs in full irrespective of the amount charged."
Of equally great concern was the practice, by certain doctors, of charging abnormally high fees for PMBs
What does it mean for you?
With medical aid schemes dipping into your savings to partly cover PMBs your savings will start to deplete at higher-than-normal rates. It is vital that you check your monthly statements from your scheme for any irregularities.
You should also query any rejected claims as some medical aid companies are intentionally confusing members, and even refusing legitimate claims, based on unethical policies.
Prevent yourself from having to pay out of your own pocket for claims by using a DSP or designated service provider. DSPs are the healthcare providers with whom schemes negotiate favourable rates, to manage the costs of the PMBs.
If all else fails, and you feel justifiably wronged, you can contact the Council for Medical Schemes.
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