Press Release - Council for Medical Schemes
The circular clarifies the policy objective of PMBs - which is to ensure that
adequate cover if always available for essential and non-discretionary health
care. Medical schemes are required by law to pay in full the costs of PMBs
obtained by a member from specified providers. The communication to schemes also
deals with five instances which Masobe believes greater certainty is required in
order that members are treated more fairly:
* First, the circular underscores the point that PMBs are not envisaged as
hospital based services only. They can also be provided in an ambulatory
setting, and schemes are obliged to pay in full for these services. The Medical
Schemes Act does not restrict the setting in which relevant care should be
provided and therefore should not be construed as preventing the delivery of
PMBs in outpatient settings where this is clinically appropriate.
* The second issue relates to designation by medical schemes of the public
health sector as a provider of PMBs. Here, Masobe points out that, although the
Medical Schemes Act allows schemes to designate the public sector as the
provider of PMBs, schemes still have the obligation to ensure that the public
sector services will be reasonably available and accessible to members. Any
scheme that purports to designate the public sector without ensuring that these
services are available will have their benefits rules rejected by the Registrar.
In those cases, members will be free to approach any other provider, and the
scheme may be liable for the full costs.
* PMBs, co-payments and deductibles - there are a limited number of instances
where a medical scheme may charge a co-payment for PMBs. These include occasions
when a member may elect to use a provider who is not part of the scheme's
designated service providers (DSPs). This does not, however, extend to cases
that are clearly of an emergency nature or the appointed DSP is not accessible
to members. In all these cases the scheme is obliged to pay for PMBs in full and
without co-payments or deductibles.
* PMBs, treatment protocols and formularies - there may be
instances where a scheme uses treatment protocols and formularies to manage PMBs.
In these instances, the law requires that these protocols and formularies should
be formulated on basis of medical evidence. Schemes are also required to make
these protocols and formularies available to members and the public on request.
This is a fundamental part of engendering transparency in the operations of
* Finally, the circular clarifies the manner in which schemes can apply
waiting periods on applicants with pre-existing conditions - Masobe's concern in
this regard is that many schemes have been imposing waiting periods in a manner
that is inconsistent with the provisions of the Act, leading to unfair treatment
of members. He says that "waiting periods should only be used as a tool to
mitigating adverse selection, and not to treat applicants unfairly".
Condition specific waiting period can accordingly be imposed in respect of
conditions that an applicant suffered from or sought medical treatment during
the twelve month period before an application for membership of the scheme was
made. While medical schemes may be entitled to request health related
information from members for disease management purposes, condition specific
waiting period may under no circumstances be imposed on members for conditions
falling outside the twelve month period.
People who were beneficiaries on another medical scheme for at least two
years and apply to join another scheme within three months of terminating their
membership of the first scheme are also not liable for imposition of the
condition specific waiting period. Once a scheme has elected to apply a waiting
period, these must be applied consistently to all new applicants and cannot vary
depending on applicant's situation otherwise this would constitute unfair
discrimination in terms of the medical schemes Act.
Finally, Masobe has invited people who believe that waiting periods may have
been imposed on them in contravention of the legislation to contact the Council
for Medical Schemes' offices for redress. All reported cases will be
investigated and appropriate steps will be taken where reasonable grounds of
unfair treatment are established.
Notes for Editors 1. The Council for Medical Schemes was created in terms of
Medical Schemes Act 131 of 1998 as a regulatory authority for medical schemes.
2. Prescribed Minimum Benefits (PMBs) are benefits set out in law which must be
paid in full as long the service was obtained from a DSP. 3. A co-payment or
deductible is a specific payment for which a member may be liable in terms of
the rules of the schemes if the member fails to use the scheme's designated
service provider. 4. Designated Service Provider (DSP) means a healthcare
provider or group of providers selected by the scheme concerned as the preferred
provider to provide PMBs to its members. 5.
Treatment protocol means a set of guidelines in relation to the optimal
sequence of diagnostic testing and treatments for specific conditions and
includes clinical practice and treatment guidelines.
More detailed information on the above mentioned Act and Regulations can be
accessed under the "Publications Portal", at www.medicalschemes.com,
and on Circular 32. on http://www.medicalschemes.com/publications/publications.aspx?catid=1
Contact:  Patricia Sidley, on 012 431 0570