Updated 02 December 2015

Medical Schemes Act: proposed amendments to PMBs

Proposed amendments to the Medical Schemes Act signal a victory for millions of medical scheme beneficiaries and allow for a more equitable and sustainable healthcare system in South Africa.

In the latest Government Gazette, Minister of Health Aaron Motsoaledi has given notice of proposed amendments to the Medical Schemes Act – specifically pertaining to regulations set out to govern Prescribed Minimum Benefits (PMBs) and the way that these are paid by medical schemes in South Africa.

Regulated tariff

According to Neil Nair, Principal Officer of SAMWUMED, the Scheme applauds the draft amendment to Regulation 8, as gazetted by the Minister of Health. “The fundamental implication of the amendment, when passed by Parliament, shall mean that all registered healthcare providers subscribe to a regulated tariff. Medical Schemes shall also be required to ensure that members receive uninterrupted treatment and care for PMB conditions, without benefit limits and/or co-payments.”

Read: What are PMBs?

He says that this signals a huge victory for millions of medical scheme beneficiaries and allows for a more equitable and sustainable healthcare system in South Africa. “The implications are more far reaching in that many schemes defaulted PMB care to the State, given the open liability enforced by the payment at cost principle.”

Nair goes on to explain that this amendment will force schemes to reconsider this in view of a regulated tariff, which will mean that costs may be more predictable and indeed more effective to allow for members to access greater choice in provider options. “In theory, this must also lead to reductions in medical aid contributions, which would be a real victory for millions of medical scheme beneficiaries.”

Last year, SAMWUMED and Genesis Medical Scheme took the Minister of Health, Aaron Motsoaledi, to court to have the regulation requiring cover of prescribed minimum benefits (PMBs) at cost to be set-aside. SAMWUMED subsequently withdrew its court application on the amendment of Regulation 8 in pursuit of a negotiated agreement with the Minister.

Battle is not over

Nair says that in light of this latest development, the Scheme feels justifiably vindicated having spearheaded the review of this regulation for many years now. “In the face of great adversity, we persevered in the knowledge that the interpretation of payment at cost was exploitative and an injustice. While the battle is not over, we do believe that the Minister’s proposed amendment acknowledges our argument made tirelessly over many years.”

Read: Medical Aid schemes are squeezing Community pharmacies and consumers

He adds that without clear regulations and regulated tariffs set out, the determination of healthcare costs cannot be left to the market and instead requires genuine effort by government to ensure an equitable playing field. “Whilst there is considerable regulation on the funding side – this must be counter-balanced on the provider side. This proposed amendment goes a very long way in achieving this equity.”

Nair says that SAMWUMED also welcomes the shift in approach by the Council for Medical Schemes (CMS), which he believes is an acknowledgement that payment at cost is not only unsustainable but immoral. “This change in thinking will usher in a fairer and indeed more compliant framework from providers.”

“SAMWUMED herewith endorses the Amendment and pledges support to see this through Parliament,” concludes Nair.

Read more:

Advocate urges litigation over PMBs

Why do we have PMBs?

Do you know which claims your medical scheme doesn't have to pay?

Image: Health insurance from Shutterstock


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