One of the leading medical schemes in South Africa, Genesis Medical Scheme, is on a mission to deregulate Prescribed Minimum Benefits (PMBs) which requires medical schemes to offer a defined set of healthcare benefits and services to all members irrespective of their chosen plan.
PMBs include chronic illness such as diabetes and HIV as well as all emergency conditions and certain cancers, all of which must be paid in full by medical schemes. PMBs are in place to ensure patients don’t have to pay out-of-pocket or out of their Medical Savings Account for these conditions, and to ensure everyone has access to healthcare services.
While the idea behind PMBs is sound, in reality PMBs create a baseline for the costing of medical aid which excludes the majority of the population. “PMBs immediately make insurance unaffordable for most because medical schemes are forced by law to cover people who are not necessarily acting responsibly for their health and wellbeing,” said Founder and Managing Director of CareCross Health, Dr Reinder Nauta, in a previous interview with eHealthNews, who believes certain schemes should be exempt from some stipulations of the Medical Schemes Act, such as PMBs.
According to Bizcommunity, in September 2014 Genesis launched an application against Minister of Health, Dr Aaron Motsoaledi, asking the Western Cape High Court to review and set aside regulations that provide for PMBs, which are made by Motsoaledi in terms of the Medical Schemes Act.
Genesis believes Motsoaledi doesn’t have the power to make these regulations, and that he is only empowered to prescribe medical conditions in the Regulations and not how medical schemes are required to pay for the treatment of these conditions. Motsoaledi has not opposed the application.
In response to Genesis, numerous patient advocacy groups, including The Treatment Action Campaign (TAC), South African Depression & Anxiety Group (SADAG) and People Living with Cancer (PLWC), are applying as amici curiae (friends of the court) to the Western Cape High Court, for they believe Motsoaledi does have the power to regulate the medical schemes by requiring the payment of PMB conditions in full and without co-payments or deductions. If Genesis is successful, they foresee patients suffering and their rights being potentially violated.
Other interested parties have also applied to the court to join the case as respondents, including the Council for Medical Schemes, Hospital Association of South Africa (HASA), South African Private Practitioners Forum (SAPPF), Multiple Sclerosis Society of South Africa and Infertility Awareness Association of South Africa. The court heard all these parties on 18 June 2015.