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29 March 2016

PMBs: when should a medical scheme pay in full?

Prescribed Minimum Benefits: must a scheme pay in full, at cost for these 270 conditions? The battle rages on, despite judgments in several court cases.

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Regulation 8 of the Medical Schemes Act states that a medical scheme, when it comes to PMBs, … “any benefit option that is offered by a medical scheme must pay in full, without co-payment or the use of deductibles, the diagnosis, treatment and care costs of the prescribed minimum benefit conditions.”

The issues at stake over the last few months have included the following:

- This provision, requiring that services be paid at cost, has led many people to believe that it in effect gives those in the private sector a blank cheque to charge whatever they please for the diagnosis, treatment, and care of any of these 270 conditions.

Read: What are PMBs?

- Initially, section 29 (1) (p) referred to PMBs with regards to public hospital patients, which was amended in 2002 by the then Minister of Health, Dr Manto Tshabalala Msimang, removing the reference to the public hospital patient. The question arose whether that amendment to the regulation overruled the Act itself, and whether she, in fact, had the authority to make that amendment.

- Medical scheme experts have questioned the "at cost" ruling, saying that the original legislators, while trying to protect the consumers, might not have foreseen the financial difficulties this provision would cause in the future to medical schemes.

- Many low-cost hospital plans are struggling to meet these PMB requirements – the only other option is to increase their contributions substantially, adding to spiralling medical inflation and placing access to private medical care even further beyond the reach of low-income earners.

Read: What you need to know about PMBs in 2016

- The only way in which a medical scheme can limit expenditure on PMBs is to require its members to make use of a designate service provider (DSP), with whom they have arranged a fixed tariff schedule. Members who use DSPs will not be liable for making any co-payments.

- A scheme does not have to nominate a DSP. If a scheme has no DSP, the medical scheme has to fit the entire bill for the treatment of PMBs, regardless of where the services were obtained.

- The Constitutional Court dismissed the application of Genesis Medical Scheme to appeal this judgment (see previous bullet point) by the Supreme Court of Appeal. This raises the question of the legal validity of your scheme’s benefit schedule and whether the Medical Schemes Act in fact overrides the provisions set therein.

- Another issue was that of low-cost benefit options. If an amendment to the Act was made, enabling low-cost medical schemes to be registered with the CMS even though they only covered some of the PMBs, then contributions could be cut increasing access to private healthcare for millions of South Africans. After many submissions and delays, the guidelines for these schemes were withdrawn in March 2016. A new deadline has not been made public.

- The proposals for the low-cost benefit options did not include care in private hospitals, or for all PMBs, but the South African Medical Association (SAMA) objected to the fact there was no cover for HIV/Aids or for heart disease – two very common conditions among South Africans. It was proposed that some of these low-cost benefit options would have cost as little as R180 per month.

Read more: 

The best medical aid in SA  

What to look out for when choosing a medical scheme 

Don't let medical aid schemes bamboozle you

Susan Erasmus is a freelance writer for Health24.

 
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