The Registrar of Medical Schemes expressed concern on Thursday that many schemes have not been providing members with the minimum benefits they are entitled to.
Another concern is the manner in which medical schemes impose waiting periods on members, especially those who would normally be entitled to receive services regarded as prescribed minimum benefits (PMBs), Registrar Patrick Masobe said in a statement.
A circular he prepared clarifies the policy objective of PMBs — to ensure that adequate cover is 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 in which Masobe believes greater certainty is required in order that members are treated more fairly.
The circular underscores the point that PMBs are not envisaged as hospital-based services only, the statement continues. 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.”
Regarding the designation by medical schemes of the public health sector as a provider of PMBs, Masobe said that although the 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.”
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.”
There may be instances where a scheme uses treatment protocols and formularies to manage PMBs. The law requires that these should be formulated on the 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 medical schemes.
Masobe’s concern on waiting periods for pre-existing conditions is that many schemes had been imposing waiting periods in a manner that is inconsistent with the provisions of the Act, leading to unfair treatment of members.
Waiting periods should only be used as a tool to mitigating adverse selection, and not to treat applicants unfairly, Masobe said.
Condition-specific waiting periods can accordingly be imposed in respect of conditions that an applicant suffered from or sought medical treatment for during the 12-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 periods may under no circumstances be imposed on members for conditions falling outside the [12] month period.”
People who are beneficiaries on a 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 [an] applicant’s situation, otherwise this would constitute unfair discrimination in terms of the Medical Schemes Act,” the statement continued.
People who believe that waiting periods may have been imposed on them in contravention of the legislation can contact the Council for Medical Schemes’ offices on 012 431 0500. — Sapa