The introduction of the national health insurance (NHI) plan, provisions of prescribed minimum benefits (PMBs) for medical aid members and increasing health-care costs are some of the worrying factors raised by SA’s medical scheme industry.
Compliance and regulatory requirements are also recognised as a significant challenge, according to a survey by PwC on strategic and emerging issues in the medical scheme industry.
According to the survey, 95 percent of schemes were under the impression that minimum benefits paid in full resulted in excessive benefits being paid by medical schemes.
While they must, by law, pay these in full, they felt that provision of PMBs to everyone would make it unaffordable for entry-level members.
PMBs are a set of defined benefits that medical schemes are obliged to pay to ensure that their members have access to certain minimum health services.
The Medical Schemes Act requires that all medical schemes pay for PMB conditions in full, regardless of the benefit option that members are on. There are 300 medical conditions listed under PMBs, including 27 chronic ones.
The survey is based on the results of an online questionnaire completed by principal officers in 20 schemes registered in SA and Namibia.
Andrew Edwards, of Liberty Medical Scheme, said the survey raised valid issues and showed the uncertainty under which schemes operated.
He said that while the introduction of PMBs, which obliged medical schemes to pay claims for PMB conditions in full, should be hailed as a victory for consumers and the regulator, the absence of guideline tariffs that regulated what doctors charged their patients made the situation open to exploitation.