The role of medical schemes

THE South African healthcare system, with its strong private sector and a public sector with many challenges, differs from other countries in that they have mostly only one healthcare system and various role players.

In this country the Council for Medical Schemes (CMS) regulates medical schemes, administrators and managed care organisations, as stipulated in the Medical Schemes Act and its role is to protect beneficiaries, maximise access to coverage and protect the public interest.

Dr Elsabe Conradie explains, “Without regulation, only private interests would prevail, reducing access and accountability.”

Of the current population of about 54 million only 8,8 million, or 16 percent, are beneficiaries of medical schemes delivering private healthcare.

There are currently 83 registered medical schemes, of which 23 are open. The remainder are restricted schemes. They offer various benefit options, allowing members to choose what is most suitable to their needs.

Benefit options offer hospital cover, optional day to day benefits and chronic benefits for prescribed minimum benefits (PMB) conditions. PMB's include 270 serious health conditions, any emergency condition, and 25 chronic diseases. PMBs were designed to offer maximum protection to members of schemes irrespective of which option they choose. They aim to ensure that when members face catastrophic healthcare events they do not ruin them financially. PMBs also aim to avoid incidents where individuals lose their medical scheme cover in the event of serious illness and the consequent risk of unfunded utilisation of public hospitals, and to encourage improved efficiency in the allocation of private and public healthcare resources.

According to Regulation 8 of the Act, medical schemes must pay PMBs in full, without co-payment or the use of deductibles, the diagnosis, treatment and care costs of the PMB conditions.