CMS: Prescribed healthcare benefits as valid as ever

Medical schemes must continue to pay for a set of prescribed healthcare benefits – and they must pay for them in full.

This is required by law, specifically the Medical Schemes Act 131 of 1998.

"Legislation has always been clear on this – and it has not changed," the Registrar of Medical Schemes, Dr Monwabisi Gantsho, said today. "The prescribed minimum benefits lie at the very heart of the medical schemes industry in South Africa and their payment in full is non-negotiable."

But the Board of Healthcare Funders of Southern Africa (BHF), a representative body for medical schemes and administrators, is adopting a different approach. It is proposing that Regulation 8 of the Medical Schemes Act – which tells schemes to pay for PMBs "in full" – be interpreted to mean that schemes are actually required to pay for PMBs at scheme tariffs.

Legal processes are currently underway with the aim to reach a final determination on the interpretation of Regulation 8.

But until a court of law makes a pronouncement on the matter, the current provisions on PMBs remain as valid as ever and the Council for Medical Schemes (CMS) will continue to enforce the requirements of the Medical Schemes Act.

Further clarity can be found in Circular 56 of 2010 on the CMS website (http://www.medicalschemes.com/files/Circulars/Circular56Of2010_20101027.pdf).

Reminder: what are PMBs?

PMBs are described in Section 29(1)(o) and Regulations 7 and 8 of the Medical Schemes Act. Every registered medical scheme must cover – in full – the 300 PMB conditions of its beneficiaries, regardless of the benefit option to which they belong. PMBs offer protection against the most serious and often life-threatening diseases and conditions.

PMB provisions require each scheme to cover all costs associated with the diagnosis, treatment and care of:

*  any emergency medical condition

* a defined set of 270 diseases, the so-called Diagnosis and Treatment Pairs (DTPs), which includes cancer and HIV/AIDS

*  the 25 chronic conditions on the Chronic Diseases List or CDL, including hypertension and diabetes