facebooktwittertwitter

Contact A Counsellor

counsellor button

KNOW MORE

teen suicide icon

 

panic anxiety icon

panic anxiety icon

#MindfulMondays with Miss SA

teen suicide icon

IN THE WORKPLACE

Research on Depression in the Workplace.

For more information please click here

business

SADAG NEWSLETTER

email subscribers list

To subscribe to SADAG's newsletter, click here

To view previous newsletters - click here

MHM JOURNAL

Mental Health Matters Journal for Psychiatrists & GP's

MHM Volume 8 Issue1

Click here for more info

JOURNALISTS

journalists crew making newspaper

If you are a journalist writing a story contact Kayla on 011 234 4837  media@anxiety.org.za

MYSCHOOL

MySchool Facebook banner Nov

It’s the small things that make a BIG difference. Sign up for the “My School | My Village | My Planet” Card and start making a difference to Mental Health in South Africa today.

Click Here

SPEAKING BOOKS

cope with cancer book

Literacy is a luxury that many of us take for granted. That is why SADAG created SPEAKING BOOKS and revolutionized the way healthcare information is delivered to low literacy communities.

The customizable 16-page book, read by local celebrity audio recordings, ensures that vital health and social messages can be seen, heard, read and understood by everyone across the world.

We started with books on Teen Suicide prevention , HIV, AIDS and Depression, Understanding Mental Health and have developed over 100+ titles, such as TB, Malaria, Polio, Vaccines for over 45 countries.

suicide speaking book

Click here to view PDF version

By Allan Sweidan
CEO Akeso Clinics & Psychologist
Johannesburg
This email address is being protected from spambots. You need JavaScript enabled to view it.

• What is PMB ?
• Debunking myths about PMBs
• Understanding chronic conditions benefit?
• Which mental illnesses are covered by PMB's and which ones are not?
• Which is the medical aid that caters best for mental health?
• What is the PMB for different medical aids or different schemes?

It’s my experience that PMB’s are not generally well understood by the general public, by many practitioners and in some cases even by medical schemes' case managers. Unfortunately, there’s not a lot of easily accessible information regarding PMB’s that can guide members along the way. In this article, I make references to certain documents which will be made available on SADAG’s website or are already available on the Council for Medical Schemes website.

PMB’s are an acronym for Prescribed Minimum Benefits - an important feature of the MedicalScheme’s Act. According to the Council for Medical Schemes (CMS) website (http://www.medicalschemes.com), PMB is a set of defined benefits to ensure all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. What this last bit means is that the benefits associated with a PMB condition are not dependent on the plan you have selected: PMB’s apply to all members of a scheme, regardless of the plan, even if it’s just a hospital plan.

Any emergency medical condition is covered under the PMB guidelines, as well as 270 medical conditions and 25 chronic conditions. When a condition is listed as having prescribed minimum benefits attached to it, this condition will be listed together with the minimum benefits associated with it. Together, the condition and treatment are referred to as Diagnosis Treatment Pairs. PMB’s as listed by the CMS, trump the benefits listed by any medical scheme if the benefits listed by the scheme are less than the benefits defined by the CMS. So it’s really important for scheme members to familiarise themselves with the PMB’s as they’re paying for these benefits, which, according to the CMS, are designed to provide patients with continuous care and to make healthcare more affordable!

Debunking Myths About PMB’s

Myth 1- Everybody knows the PMB’s

The biggest myth about PMB’s is that everyone who is supposed to be familiar with them is in fact familiar with them! This is a myth, and if there’s one message I can convey to the reader it’s this: Know Thine PMB Rights!

Myth 2 – The PMB for mental health is 21 days in hospital per annum

There are in fact 11 different PMB mental health conditions, and each has its own Prescribed Minimum Benefits. However, the myth remains that there’s one benefit for mental health - 21 days in hospital per annum. This is not true, but more about that later.

Myth 3 – Despite being legislated, all medical aid schemes will honour the PMB’s

Despite losing a case last year in which it challenged an important aspect of the PMB’s, a certain minor Medical Scheme, continues to dishonour mental health PMB conditions. After the Life Esidemeni tragedy, it’s unfathomable to me how a medical scheme might act in such a way. Know your rights and fight for them!

Understanding chronic conditions benefits

There are just two chronic mental health PMB conditions: Bipolar Mood Disorder and Schizophrenia. There are treatment algorithms for these two conditions, and for the purposes of most of the readers of this journal, the relevant bits are about the medical management of these two conditions, which by their chronic nature, require ongoing and not acute or short term treatment.

For Schizophrenia, the guidelines state:

1. Medical management reasonably necessary for the delivery of treatment described in this algorithm is included within this benefit, subject to the application of managed health care interventions by the relevant medical scheme.

2. To the extent that a medical scheme applies managed health care interventions in respect of this benefit, for example clinical protocols for diagnostic procedures or medical management, such interventions must –
a. not be inconsistent with this algorithm;
b. be developed on the basis of evidence-based medicine, taking into account considerations of cost-effectiveness and affordability; and
c. comply with all other applicable regulations made in terms of the Medical Schemes Act, 131 of 1998.

3. This algorithm may not necessarily always be clinically appropriate for the treatment of children. If this is the case, alternative paediatric clinical management is included within this benefit if it is supported by evidence-based medicine, taking into account considerations of cost-effectiveness and affordability.

Bipolar guidelines are worded slightly differently so as to include allied health interventions (psychologists, occupational therapists etc.)

1. Medical management reasonably necessary for the delivery of treatment described in this algorithm. This management includes provision for allied health support, consultation(s) to collect collateral information, and group therapy when indicated, but is subject to the application of managed health care interventions by the relevant medical scheme.

2. To the extent that a medical scheme applies managed health care interventions in respect of this benefit, for example clinical protocols for diagnostic procedures or medical management, such interventions must –
a. not be inconsistent with this algorithm;
b. be developed on the basis of evidence-based medicine, taking into account considerations of cost-effectiveness and affordability; and
c. comply with all other applicable regulations made in terms of the Medical Schemes Act, 131 of 1998.

3. This algorithm may not necessarily always be clinically appropriate for the treatment of children. If this is the case, alternative paediatric clinical management is included within this benefit if it is supported by evidence-based medicine, taking into account considerations of cost-effectiveness and affordability.

The full algorithms for schizophrenia and BMD can be accessed via the SADAG website Bipolar Mood Disorder Chronic Benefit Algorithm - http://www.sadag.org/images/pdf/Bipolar-Mood-Disorder-Chronic-Benefit-Algorithm.pdf
Schizophrenia Chronic Benefit Algorithm - http://www.sadag.org/images/pdf/Schizophrenia-Chronic-Benefit-Algorithm.pdf

What does ‘medical management for the delivery of treatment actually mean?

After trawling through the web pages of medical schemes, it remains unclear what the schemes will or won’t pay for regarding the necessary medical treatment for BMD or Schizophrenia. My suggestion to members of schemes, is to contact your scheme after being diagnosed with a chronic condition to find out what they will cover. Remember to remind them that the condition has PMB’s attached!

Which mental Illnesses are covered by PMB’s and which are not?

The box below details the mental health conditions associated with the PMB’s. My understanding of the table (taken directly from the CMS website) is that there are separate and discrete mental health conditions that have PMB’s.

Which is the medical aid that caters best for mental health?

In the past few years, most medical schemes have recognised that mental illnesses have a profound impact on their members’ disability profiles and if untreated, can complicate the treatment and increase the costs of covering some general medical conditions by up to 600%. As a consequence, most schemes honour the PMB’s and will authorise treatment for mental illness in line with the PMB’s. The primary differentiating factor between the schemes, is whether they have contracts in place with Designated Service Providers (DSP) for PMB conditions. Because the CMS rules state that the cost of treating a PMB condition must be covered ‘in full’ by the schemes, the schemes will sometimes enter into relationships with DSP’s (DSP’s can be hospital networks, practitioner networks and pharmacies) to provide this treatment. In this way, the DSP’s will have more patients as the schemes channel their members to them, and the scheme can in turn negotiate better prices and sometimes higher levels of quality. Whether a scheme has entered into a contract with a DSP or not is something members should ask at the beginning of every renewal period, as these relationships are negotiated annually. If a member receives (nonemergency) care related to a PMB from a provider that is not a DSP, then the member can be liable for a co payment. So, the best medical schemes are the ones that provide the most convenient access to care.

mental illness codes

The chronic condition known as fibromyalgia affects tens of thousands of South Africans. Unfortunately, the medical profession, and also the medical aid industry, do not take this condition seriously.

In fact, doctors are fond of telling patients who suffer endless body pain as a result of this condition that they are “imagining it” and that they should “get over it and get lots of sleep and exercise”.

The fact that thousands of patients experience endless pain and sensitivity all over their bodies has done nothing to change the medical view of the condition. Apparently, doctors and specialists are happy to accept that thousands of people have nothing better to do with their time than dream up this illness.

Because of the reputation of the illness as a psychosomatic illness, the Council for Medical Schemes does not rate it a chronic condition. It regards only 26 conditions as chronic and mandatory by law for medical schemes to cover. These include illnesses such as cancer, multiple sclerosis, epilepsy and glaucoma. (Go here - http://www.medicalschemes.com/consumer/Rights.aspx#1 -  for the full list of the 26 conditions covered by the Prescribed Minimum Benefits or PMBs.)

The Council – the body instituted in terms of the Medical Schemes Act regulations – regards a chronic condition as a common condition which is life threatening and for which treatment would improve the quality of life of the patient. Fibromyalgia sufferers would argue that this condition does qualify in terms of this definition of PMBs.

Medical researchers have recently started to pinpoint the cause of fibromyalgia – it apparently has to do with an excess of certain nerve fibres in the hand – but a cure is still nowhere in sight. All that doctors and specialists can offer are painkillers, anti-depressants, psychotherapy, physiotherapy and patronising advice – none of which eases the pain of the sufferer.

Ironically, the SA Depression and Anxiety Group does include fibromyalgia as a chronic condition. However, the implication is that this disease is a kind of mental illness rather than a physical one.

Wikipedia describes fibromyalgia as chronic body pain and a painful response to pressure on the skin. But then it also associates the condition with depression and post-traumatic stress syndrome.

It seems that, as long as confusion reigns about the cause of fibromyalgia, the medical profession will treat it lightly and the medical aid schemes will treat it on the same level as they treat the common cold and influenza.

*If you are a fibromyalgia sufferer and you are looking for medical cover for this condition, contact some of the leading medical aids such as Discovery, Genesis, Sanlam, Liberty, Momentum and Bonitas to find out how they regard the condition and what option they recommend.

To view the larger PDF version - click here

minimum benefits1

minimum benefits2

By: LETITIA WATSON MEDICAL COVER Prescribed minimum benefits: What the changes mean Will the proposed amendments end up benefitting schemes and sticking it to their members? By: LETITIA WATSON MEMBERS ARE confused and doctors are worried, but medical schemes sighed with relief when the Minister of Health, Dr Aaron Motsoaledi, published proposed changes to the Prescribed Minimum Benefits (PMBs) regulations in the Government Gazette last month. An amendment to Regulation 8 of the Medical Schemes Act has been long overdue-and it happened in the middle of (and maybe partly because of) a court case against the Department of Health regarding PMBs and the Competition Commissions' inquiry into the private healthcare market. A red-hot thorn in the side Medical schemes have lamented PMBs as a major cost driver since their introduction in 2004. Regulation 8 currently requires schemes to pay for the diagnosis, treatment, and care of PMBS-- which include 270 conditions and 27 chronic illnesses-at provider cost in full, regardless of which benefit option the member belongs to. According to schemes, this has opened the door for service providers to charge specifically higher for PMB conditions, as they had the certainty that the bill would be footed. "Some providers charge exorbitant fees for PMB services, and due to this regulation, medical schemes were forced to pay these fees," says Dries la Grange, chief executive of Bestmed, one of the country's largest open schemes. The open-ended costs relating to PMB conditions make it hard for schemes to manage expenditure on claims. They say that the raised expenditure results in high health inflation, translating into higher premium increases for members. This guarantee of payment apparently also created an incentive Page 10 September 2015 for service providers to up-code certain conditions as PMBs, with the benefit of increasing their revenue, and (on the other hand) assisting patients to access scheme risk benefits. Bipolar mood disorder, for instance, is eligible for PMB coverage, but other forms of depression are excluded. lt is alleged that many patients are subsequently coded as having BMD. Ditto for pneumonia (which is a PMB) and bronchitis (which is not). The amended regulation proposes that schemes be allowed to limit what they pay for prescribed minimum benefits to the rates set out in the 2006 national health reference price list (NHRPL), adjusted at consumer price inflation; or at a rate agreed with the service provider. What worries members Schemes say that the proposed amendments will ultimately translate into lower average premium increases for members. Members are concerned, however, that if schemes be allowed to limit what they pay for PMBs, they will end-up paying the difference between the scheme rate and the service providers' fee out of their own pocket-and although the draft regulations do not appear to compromise the care provided, members are worried that capping the cover could reduce access to the quality of healthcare they currently receive. Dr Humphrey Zokufa, managing director of the Board of Healthcare Funders, which represents some schemes, says that members will not be faced with co-payments, "as the medical schemes must pay in full the regulated fee. This is the case even when the fees are negotiated outside the 2006 NHRPL model." Notwithstanding the changes to Regulation 8, co-payments for PMBs are not new. Although PMBs are covered in full, this doesn't mean that members can pick and choose between medication and service providers. Schemes have their own cost- curtailing measures such as using designated service providers (DSP), as well as networks of specific doctors and hospitals to supply services at a pre-agreed rate. If members use non DSPs on a voluntary basis, they could be faced with co-payments. Dr Johnny Broomberg, chief executive of Discovery Health (DH), says that one interpretation of the amended regulation, which appears to be the intention of the National Department of Health, is that health professionals will remain free to set their own charges for PMB treatments. "If this is correct, it does mean that where schemes do not have payment arrangements, members of those schemes might face more frequent (and perhaps higher) co-payments, since doctors will continue to charge at above the scheme rate (generally equivalent to NHRPL 2006 inflation adjusted) for all services, but schemes will no longer be obligated to pay these fees in full for treatment of PMB conditions," he says. Impact limited for some For members of schemes that already have agreements in place with service providers, the impact of the new regulation should be limited since the vast majority of provider claims are paid in terms of the contracted rates. Broomberg says, however, that if the regulations are implemented as proposed, those schemes which have not implemented contracted payment arrangements would now have to decide whether to increase their tariff costs by introducing payment arrangements in order to avoid their members experiencing PMB co-payments. Also, according to Neil Nair, principal officer of SAMWUMED, schemes will be required to ensure that Moneyweb's PERSONAL FINANCE members receive treatment and care for PMBs, without benefit limits or co- payments. Treating providers fairly The uncertainty around reasonable reimbursement weighs heavily on health care professionals. The amended regulation refers to rates set out in the 2006 NHRPL, adjusted for consumer price inflation, but the South African Private Practitioners' Forum (SAPPF) says that it does not represent the actual costs of running a private practice. In July 2010 a High Court ruling declared the publication of the NHRPL invalid, rendering any such rates null and void. This ruling is applicable to the 2008 and 2009 price lists, and is retrospective. It found that the process by which the rates were determined to be unfair. Dr Chris Archer, chief executive of the SAPPF, says that the reference price list has no relation to the actual input costs of health professionals. As just one example of numerous input cost factors that the 2006 NHRPL doesn't take into account, he cites the steep increase in mal- practice insurance premiums for obstetricians over the past ten years. Over the past decade, Archer says, the annual premium increased from around R16 000 to R450 000, with expectations of over RI million by 2018. Doctors should be able to cover costs such as these. uninterrupted Archer also says that the proposed amendment flies in the face of the Health Department's submission to the Competition Commission, which proposes a cost -based tariff that is independently produced. Health professionals also fear being bullied into accepting network tariffs that are set at levels below cost. In their submission to the Private Health inquiry, the South African Medical Association states that despite perceptions that medical practitioners are in a strong position because the market is reliant on their skills and services rendered, the converse is actually the case. "Medical doctors in the private sector are almost entirely reliant on the medical funding industry to remain in business. It is, in fact, the scheme industry which occupies the dominant market position." Broomberg adds that the amended regulation could encourage those providers who have not entered into such contracts to join contracted payment arrangements, since they may otherwise face an increase in bad debts and collection costs as they will have to collect co-payments much more frequently. According to Broomberg, the payment arrangements of schemes administered by DH typically reimburse providers from 55% to 117% above the inflated NHRPL figure. Archer however argues that the agreements are not negotiated, but imposed on health care practitioners. "If reimbursement is limited to scheme rules, it will bankrupt the provider industry. No industry in the world can survive if input costs are not considered," he says. Where to from here? The amended regulation is in draft form, and will remain open for comment for three months before being finalised. It is very likely that it will be challenged by various parties, and that the process of implementation will be somewhat delayed. The court case between Genesis Medical Scheme and the Minister of Health is also under way. Last year, SAMWUMED and Genesis took the Minister to court to have the regulation requiring cover of PMBs at cost to be set-aside. SAMWUMED has subsequently withdrawn its court application. Genesis argues that although the minister may determine the list of conditions that comprise the PMBs, he has no power to regulate the scope of payment. The Minister has indicated that he will not be opposing the case. Many organisations that could be affected by the outcome have applied to join the case, including the Treatment Action Campaign, the South African Depression & Anxiety Group, People Living with Cancer, Mediclinic Southern Africa, the Hospital Association of South Africa, the Council for Medical Schemes, and the SAPPF.

The Council for Medical Schemes (CMS), regulator of the medical schemes industry, advises medical scheme members to use their benefits wisely – especially at the beginning of the year – with the aim of making their benefits last longer.

Acting Chief Executive and Registrar of the CMS, Daniel Lehutjo, says now that members have chosen to either stay on the same benefit option or move to another one, they should resist the urge to spend all their benefits in the first couple of months to avoid running out of cover when it may be needed the most, later in the year.

“We appeal to members to also use their medical scheme benefits wisely and spread the use of it evenly during the year. Make use of your general practitioner (GP) to coordinate your care and discuss any healthcare needs and concerns for the year – the CMS latest annual report shows schemes that paid more benefits to GPs paid less benefits to hospitals, indicating care coordinated by GPs decreases the chance of members being hospitalised.”

The most common advice is to not use your benefits to buy sunglasses, multivitamins or other lifestyle items over the counter, but instead use it for essential medicines when the need arises. Members are also advised to ask their doctors to prescribe in formulary drugs (list of drugs that will be funded by medical schemes for each condition).

A formulary regularly consist of generic medication, especially in higher schedule categories, which is generally cheaper and thereby save funds while it is just as effective as the more expensive alternative.

“We encourage people to make use of the preventative screenings and tests many schemes offer. Members should also seek to register on the relevant chronic management programmes if they have certain illnesses, thereby ensuring their condition is monitored and that they receive all the necessary care,” explained Lehutjo.

Should an emergency arise, or any of the 270 medical and certain chronic conditions occur, medical scheme members can rest assured that they are covered through prescribed minimum benefits (PMBs). Schemes have to pay for PMBs in full from the risk pool according to the Medical Schemes Act 131 of 1998, except where a member voluntarily uses a non-Designated Service Provider (DSP).

There is also a false believe that schemes only pay for PMBs and do not fund other non-PMB conditions. An analysis of selected schemes in the CMS Annual Report shows PMBs constituted 52.5% of the R102.2 billion paid for all risk benefits, meaning 47.5% of this amount was paid for other conditions.

However, members need to know the rules of their schemes and what benefits are included in their specific benefit option to know which non-PMB conditions are included in their option.

There are medical interventions available over and above those prescribed for PMB conditions but schemes may choose not to pay for them.

The following advice will greatly assist members to determine if and how much they are likely to pay out of their own pockets:

  • Contact your medical scheme and ask who the DSP is for the service or product that you need.
  • If you need to undergo an operation, ask your surgeon for the codes that will be charged. This will include the procedure codes and those for any other products that is needed, such as an internal prosthesis that will be used.
  • Discuss the medical scheme tariff with your surgeon and negotiate the price that you will pay.
  • Contact your medical scheme and ask whether the specific type of product will be funded in full. If not, make sure that you know what part of the cost will be for your own pocket.
  • Ask your scheme to provide you with a list of DSPs for the product or procedure you need to undergo. The scheme may appoint a surgeon, hospital and anaesthetists as designated service providers. These providers usually have agreements with the schemes for non-PMBs as well.
  • Where possible, ask the provider to assist you with obtaining codes from several companies. It should be noted that your doctor may have preferences based on your clinical condition. In this instance you as a member will not have sufficient evidence to shop around for better quotations.
  • Determine if there is a shortfall and make plans how this will be funded.
  • Obtain pre-authorisation for procedures as provided for in the rules of your medical scheme.

The amendment to Regulation 8 of the Medical Schemes Act, what does it mean?

This Brief discusses the amendment to Regulation 8 of the Medical Schemes Act and what it actually means to members of medical schemes and other stakeholders.

Introduction

Regulation 8 of the Medical Schemes Act 131 of 1998 deals with Prescribed Minimum Benefits (PMBs) for a range of 270 medical conditions [1].  Every medical aid scheme must cover all these conditions.  Specifically, Regulation 8 sets out rules for the payment for expenses of the diagnosis, treatment and care costs of a PMB benefit condition. These payments are met by the medical aid scheme with copayments by members under certain conditions

A draft amendment was circulated by the Department of Health on 14 July 2015. Neil Nair of Principal Officer of SAMWUMED [2] has described it as follows:

The fundamental implication of the amendment, when passed by Parliament, shall mean that all registered healthcare providers subscribe to a regulated tariff.

But what the amended regulation means is not luminously clear.  We have struggled to interpret it and we offer our understanding below.  If we have it wrong, we would welcome correction.

Regulation 8 states (amendment in italics):

(1) Subject to the provisions of this regulation, 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.

(2) Subject to section 29 (1) (p) of the Act, the rules of a medical scheme may, in respect of any benefit option, provide that— (a) the diagnosis, treatment and care costs of a prescribed minimum benefit condition will only be paid in full by the medical scheme if those services are obtained from a designated service provider in respect of that condition;  

(b) a co-payment or deductible, the quantum of which is specified in the rules of the medical scheme, may be imposed on a member if that member or his or her dependant obtains such services from a provider other than a designated service provider,

provided that no co-payment or deductible is payable by a member if the service was involuntarily obtained from a provider other than a designated service provider and:

either

 (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, the Rand value of which has been adjusted annually in accordance with the Consumer Price Index as published by Statistics South Africa;

 or

(ii) schemes may negotiate alternative tariffs with any provider of any relevant health service for which no co-payment or deductible is payable by a member

 (3) For the purposes of sub-regulation (2) (b), a beneficiary will be deemed to have involuntarily obtained a service from a provider other than a designated service provider, if— (a) the service was not available from the designated service provider or would not be provided without unreasonable delay; (b) immediate medical or surgical treatment for a prescribed minimum benefit condition was required under circumstances or at locations which reasonably precluded the beneficiary from obtaining such treatment from a designated service provider; or (c) there was no designated service provider within reasonable proximity to the beneficiary’s ordinary place of business or personal residence.

(4) Subject to sub-regulations (5) and (6) and to section 29 (1) (p) of the Act, these regulations must not be construed to prevent medical schemes from employing appropriate interventions aimed at improving the efficiency and effectiveness of health care provision, including such techniques as requirements for pre-authorisation, the application of treatment protocols, and the use of formularies.

(5) When a formulary includes a drug that is clinically appropriate and effective for the treatment of a prescribed minimum benefit condition suffered by a beneficiary, and that beneficiary knowingly declines the formulary drug and opts to use another drug instead, the scheme may impose a co-payment on the relevant member.

(6) A medical scheme may not prohibit, or enter into an arrangement or contract that prohibits, the initiation of an appropriate intervention by a health care provider prior to receiving authorisation from the medical scheme or any other party, in respect of an emergency medical condition.

The logic of Regulation 8 as amended:

Expenses incurred by a medical aid scheme member for a PMB condition are met by the scheme, with or without a copayment by the member.  Our understanding of the logic that the amended Regulation 8 sets up can be put as follows:

1. Does the medical aid scheme designate service providers?

If the answer is NO, there is no copayment by the member.

If the answer is YES, go to Question 2.

2. Was the service provided by a designated service provider?

If the answer is YES, there is no copayment by the member.

If the answer is NO, go to Question 3.

3. Was the choice of a non-designated provider voluntary (see subsection 3 above)?

If the answer is NO, there is no copayment by the member.

If the answer is YES, go to Question 4.

4. Has the medical aid negotiated an alternative tariff with the non-designated provider?

If the answer is YES, there is no copayment by the member (see subsection 2(b)(ii)).

If the answer is NO, a copayment equal to the difference to the fee charged by the provider and the NHRPL tariff is due from the member.

What does this mean for medical aid scheme members?

The regulation as amended means that in most cases, a member of a medical aid scheme will not have to make a copayment for expenses incurred for a PMB condition.  The exception is when a member of a scheme with designated service providers chooses a non-designated provider voluntarily and the scheme has not negotiated an alternative tariff with that provider.

Accordingly, we are puzzled by the SAMWUMED statement.  We don’t see that the amended regulation 8 was implying that all registered healthcare providers subscribe to a regulated tariff.  For one thing, different medical aid schemes may set different tariffs for the same service when they designate service providers.  Secondly, when medical aid schemes negotiate with non-designated service providers, new differences in tariffs may emerge. Thirdly, non-designated service providers with no medical aid scheme contracts remain free to set their own tariffs.

Rather, it seems to us that the main effect of the amendment is to establish a minimum medical aid scheme contribution (equal to the NHRPL tariff) in cases where copayments are required.  This was not done by the unamended regulation 8.  Of course, the amendment like the current regulation 8 means that the consumer may have to meet large co-payments under certain circumstances [3].  In a July interview with the Department of Health Head of Regulation and Compliance, Anban Pillay, stated that patients did face risks but he assured the Board of Healthcare Funders that consumers would be protected [4].  

Umunyana Rugege from Section 27 has observed that medical aid scheme members will no longer have the certainty as to whether their emergency, chronic conditions or cancer illnesses will be paid in full [5]. She went on to state that the Minister of Health’s proposals have not been accompanied by any policy documents or analysis of the medical schemes industry. Section 27 also stated in a press statement issued on 24 July that, even though the amendment does refer to the 2006 NHRPL Tariff, this tariff was intended to be an interim measure, and, even at the time when it was introduced, it did not reflect the actual cost of providing health care services. [6].

On our interpretation, medical aid members will be able to avoid copayments if they wish to.  Where service providers are designated, their use will not attract copayment.  Moreover, copayments will not be required if, in an emergency, a non-designated provider has to be used.  In non-emergency situations, medical aid members will have to weigh up the benefits of using a non-designated provider against the cost of copayments.  This calculation will be made if a member expects superior service from a non-designated provider.

More controversy around regulation 8 and PMBs

The Genesis Medical Scheme wants the Cape Town High Court to get rid of the requirement that schemes pay for the prescribed minimum benefits in full.  Genesis states that the regulations under the Medical Schemes Act have no legal standing, since they go beyond the powers afforded to the Minister.  Genesis CE Brian Watson said that “a better question to ask is: are doctors charges justified? The real issue is doctors are being given a blank cheque” [7].  Some believe that Genesis has gone to Court on the basis that it faced potentially ruinous claims for PMB conditions; however this was denied by Mr Watson [8].

The South African Private Practitioners Forum is challenging Genesis’s Court application and a multitude of parties, including the Council for Medical Schemes, Hospital Association of South Africa and the South African Private Practitioners Forum have also applied to oppose such an application. Treatment Action Campaign (TAC), South African Depression and Anxiety Group (SADAG) and People Living with Cancer (PLWC) have applied to be friends of the court in this matter. These groups argue that the Minister has the power to make regulation 8 and that regulation 8 is necessary to give effect to the right to access healthcare services under section 27 of the Constitution [9].

Dr Archer from the South African Private Practitioners Forum stated that the amendments offered protection to medical schemes at the expense of the consumer as it allowed them to limit their exposure to a reimbursement rate set in 2006 (as stated above) [10].

Conclusion

Regulation 8 and the proposed amendments have attracted criticism by various stakeholders. It seems to us that this amendment is intended to balance protection of members against the protection of medical aid schemes in light of very high claims. Will it work?  Only time will tell.

Arvitha Doodnath is Legal Researcher at the Helen Suzman Foundation.

This article first appeared as an HSF Brief.

Sources:

1. See here.      

2. Council for Medical Schemes speaks on prescribed minimum benefits by Tamar Kahn

3.  Ibid.

4. Medical aid change to benefit funders by Tamar Kahn accessible on: http://www.bdlive.co.za/national/health/2015/07/20/medical-aid-change-to-benefit-funders

5. Hands off our PMBs by Section 27 issued 24 July 2015

6. Doctors and Genesis scheme in benefits row by Tamar Kahn

7. Ibid.

8. Note 5 above.

9. Ibid.

Our Sponsors

Our Partners