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Despite Challenges, Members Of Medical Schemes Have Generally Been Well Served By Prescribed Minimum Benefits

21 January 2019 Grace Khoza, General Manager for Stakeholder Relations at the Council for Medical Schemes
Grace Khoza, General Manager for Stakeholder Relations at the Council for Medical Schemes

Grace Khoza, General Manager for Stakeholder Relations at the Council for Medical Schemes

When you or a member of your family suddenly find yourself needing medical treatment or surgery, the only thing on your mind is getting the best medical attention, not worrying whether your medical scheme will pay or not.

For many years this conundrum hung over the healthcare sector until the introduction of Prescribed Minimum Benefits (PMBs), a set of minimum benefits that must be provided to every beneficiary of a medical scheme, funded in full, without a co-payment or the use of deductibles subject to the use of the scheme’s designated service providers (DSPs), except in an emergency situation. The medical schemes must pay for PMBs from the scheme’s risk pool, and not from a member’s medical savings account.

Seven years after the North Gauteng High Court ruled that the PMBs conditions as defined in the Medical Schemes Act must be paid in full, subject to the use of DSPs, is the industry better off and are members benefiting from the PMBs?

Just to recap. The PMBs have been set to ensure members of medical schemes do not lose their medical scheme cover in an event of a serious illness, and the resultant risk of unfunded use of public hospitals. This means that, even if a member's benefits for a year have run out, the medical scheme must pay for the treatment of PMB conditions which include 270 serious health conditions, emergency conditions and 25 chronic diseases, whether someone is on a low-cost hospital plan, or high-cost medical scheme.

PMBs include diseases and chronic conditions like asthma, schizophrenia, HIV, high blood pressure, epilepsy, some heart conditions and cancer treatments, as well as emergency medical treatment.

The provisions for dealing with payment for PMB conditions have not stopped some schemes from dipping into member’s savings to pay in full for emergency care while also expecting members to foot sizeable portions of the bills of some professionals.

Some medical schemes are ducking their responsibilities to cough up, by hiding behind the interpretation of the regulations regarding the issue of payment “in full.”
It is not surprising that a significant number of the complaints received by the Council for Medical Schemes were about the manner in which medical schemes handled the issue of payment for prescribed minimum benefit conditions.

Complaints received from members regarding PMBs in 2017 related to among others, short-payment of PMB accounts by medical schemes; the issue of designated service providers; incorrect coding, as well as payment of costs for PMB conditions from members’ savings accounts.

In the year that medical schemes spent R160.6 billion on healthcare benefits, an increase of 6.04% from R151.2 billion in 2016, expenditure on PMBs was R79.2 in 2017. This means that expenditure on PMBs constituted 49% of all expenditure on risk benefits (R144.4) million.

The bulk of medical schemes’ expenditure continues to be dominated by hospitals, specialists and medicines costs, with private hospitals responsible for R58.9 billion compared to R56.3 billion during the previous year.

Prescribed minimum benefits aim to ensure that all medical scheme members have access to certain minimum healthcare services regardless of the benefit option they are on, so as to provide people with continuous care to improve their health and well-being.

In line with the National Health Act, every healthcare provider must inform members or patients about their health status (except in circumstances where substantial evidence indicates that such disclosure would not be in the best interest of the member or patient); the range of diagnostic procedures and treatment options available to the member or patient; the risks, benefits, costs and consequences associated with each of the options; and the member or patient’s right to refuse healthcare services. The healthcare provider must explain to the member or patient, the implications, risks, and obligations of such refusal of treatment.

Members of medical schemes must be informed of their responsibility to obtain relevant details regarding the PMB level of care, the available basket of care and medicine formulary; including the responsibility to provide such information to the treating provider.

In this regard, the service provider is required to provide the member, and the scheme, with the relevant information in a situation where the treatment required is beyond the standards specified in the benefit definitions.

Despite challenges, members of medical schemes have generally been well served by the PMBs. With the proper cooperation of all role-players involved, including medical schemes and providers; and proper education of medical scheme beneficiaries regarding PMB benefits by medical schemes, PMBs can go a long way in alleviating the burden of healthcare costs often faced by members when they are faced with any of the PMB conditions.

 

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