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The Rights and Responsibilities of Medical Aid Scheme Members

25 September 2022
The industry regulations, rules and medical aid products are extremely intricate and near impossible for some scheme members to navigate to access their legislated benefits and rights as set out in the Medical Schemes Act (MSA).
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Medical Aid Schemes are “not-for-profit “entities owned by us, the members - I liken it to our healthcare “stokvel”.

Here are some important elements to be aware of:

  1. In terms of Regulation 8 of the MSA, it is mandatory for all Medical Aid Plans to cover in full the diagnosis and treatment of the 27 chronic and 271 acute medical conditions called Prescribed Minimum Benefits or PMBs. The treatment does not have to be hospital based, for example Menopausal Management is a PMB.
  2. Your application to join a Medical Aid Scheme must include full disclosure of all previous and existing medical conditions and consultations.
  3. It is of utmost importance, if the medical scheme member wants their PMB claims paid in full with no co-payments, that they always use Designated Service Providers applicable to their Plan Type. You can obtain these via email or SMS and always be sure to request a call reference number.  This does not apply to Medical Emergencies, where, in terms of Regulation 8(3) of MSA, members can use any service provider closest to them.
  4. In terms of PMB regulations, a condition is an emergency if failure to treat it immediately may result in one of the following three outcomes: a serious impediment to bodily function, serious dysfunction of a body part or organ, or death. Where a condition has been confirmed as requiring emergency treatment – severe chest pains; serious car accident; swollen limbs - but has not yet been confirmed as a PMB - your medical scheme must cover the costs of all diagnostic tests and consultations until the tests confirm that the condition is no longer classified as a PMB (Source: CMS Publications CMScript 2 of 2016 Emergency Medical Conditions).
  5. Once you have been diagnosed with a Chronic or PMB condition your doctor must apply for approval of a diagnostic and treatment “basket-of-care”.
  6. Because pathology labs and pharmacies submit all accounts directly to medical schemes, you must ensure they contain DIAGNOSTIC ICD10 Codes to prevent payment from your Medical Savings Account or pocket.

The industry holds reserves of R92.97 billion and a solvency rate of 44.55% (legislated solvency is 25%). These are members’ funds and are increasing every year. Reserves are set aside to cover catastrophic events (Source: CMS Industry Report 2020/2021).

That the Council for Medical Schemes (CMS) last reviewed the PMBs in 2013 is no excuse for the fact that benefits for oncology and mental health have remained stagnant for the past 5 years, despite our contributions increasing annually.

The CMS Website contains very important and helpful information for Medical Aid Members. Please use it wisely.  

~ Written by Angela Drescher.
Consumer Healthcare Rights Activist and advocacy, Stakeholder in the Health Market Inquiry.

PMB - Prescribed Minimum Benefits
DSP - Designated Service Provider
CMS - Council for Medical Schemes
MSA - Medical Schemes Act