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Two massive medical aid changes coming in 2017 that you need to know about

Two massive medical aid changes coming in 2017 that you need to know about

The National Treasury has introduced two new medical scheme regulations which will see a limit on the amount of gap cover and hospital cash-back policies you can claim, as well as the discontinuation of all primary healthcare policies.

This is an effort to differentiate between “medical scheme products” and “health insurance”, both of which are regulated by separate Acts causing confusion in the medical arena.

The regulations, which were demarcated in terms of the Long-term and Short-Term Insurance Acts, will come into effect as of 1 April 2017 for new policies and retrospectively from January 2018 for existing policies.

Gap Cover and cash-back plans

The new regulations stipulate that hospital cash-back plans are limited to paying their clients a maximum of R3,000 per day, or a total lump sum of R20,000 per year. Currently there are no limits in place for these payments.

Gap cover policies will now also be limited to a payout of R150,000 per annum, per client.

These changes are in place to try and prevent doctors from charging high tariffs as they “have no need to compete on either price or quality in order to attract patients,” said Heath Minister Aaron Motsoaledi.

What it means for you: In theory this should equate to you actually paying less as doctors cannot take “advantage” of you and your hospital bill. However complications could arise if you have a valid reason to surpass the hard limits introduced by the regulations, depending on your current plan.

Primary healthcare policies

The new regulations will now outlaw primary healthcare policies from 1 April.

According to legislation these are not seen as full medical schemes, instead providing limited medical service benefits, such as GP visits, basic dentistry and optometry, and some acute and chronic medication.

As a result their contribution is substantially lower than full medical schemes or hospital plans contributing to static membership growth in South Africa, with only 1.4 million new principal members (with 2.2 million beneficiaries) joining since the year 2000.

Medical Schemes have traditionally been considered the realm of South Africa’s elite and these new regulations should improve the overall standard of healthcare in South Africa.

However, until new low-cost options are introduced to replace primary healthcare policies in legislation, this regulation may have the opposite effect as many lose their benefits.

What it means for you:  Insurance companies should have been informed of the incoming legislation and subsequently informed you of any changes to your policies. If you believe you are being affected and have not been contacted, we suggest you contact your insurer immediately. 

While low-cost benefits options (LCBO’s) will eventually close the gap left by this regulation they have their own unique set of problems that need to be introduced. The Medical Schemes Act currently prescribes that 270 Prescribed Minimum Benefits be provided to all members at cost. This can however be an expensive endeavour and leaves little room for low-cost options.

Further changes will have to be made to the Schemes Act to address this issue but in the time-being those who cannot afford to make the jump could be left in the dark.

Read: The cost of healthcare in South Africa

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  • Clive Naidoo


  • Wollie Verstege

    Re Gap Cover:
    “These changes are in place to try and prevent doctors from charging high
    tariffs as they “have no need to compete on either price or quality in
    order to attract patients,” said Heath Minister Aaron Motsoaledi.”

    I call BS. The doctors will still charge the high rate, you’ll just HAVE to find the money if you want to live.

    • I dont know better

      You will be surprised how often you get a cheaper price for medical expenses, if you tell the doctor that you don’t have medical aid

      • Wollie Verstege

        You must let me know which doctor that is. Our GP is usually prepared to reduce the price if we pay cash, but non of the specialists – where gap cover usually applies – have ever given us a discount.

        • I dont know better

          ahhh yeah, specialists are something else

          • Jacobus Pienaars

            And they exploit the city they are is as well. I know a guy who had to see one in Jhb. He got a price and then started phoning some in Cape Town. It turned out he coul get an appointment in Cape Town, fly down, visit friends and fly back the next day and STILL be R200 up on the Jhb quote.

        • Jacobus Pienaars

          And I bet he declares that cash for income tax.

  • robmanzoni

    What could possibly be the point of government’s interference in how much a patient is paid by an insurance company?
    Is this perhaps being driven by other vested interests with good government contacts?

    • Tony

      If any “policy change” confuses you the answer is almost always MONEY. Definitely driven …. !

    • Thinus

      We are being forced to take out more expensive medical aid plans due to the medical aid scheme’s financial losses during the past 2 years, which was Zuma’s doing for the most part. This government is nothing but the face of big business in every department, once every 4 years they will talk about issues regarding the people that keep them in power & after the election it business as usual.. in the literal sense. Look closely at every decision from this government that makes no sense but gets pushed through anyway & you will find big business behind the Muppet steering the way.

  • LAS Sutherland

    “Left in the Dark” is belittling the gross misconduct perpetrated as they will literally now end up paying BOTH a medical aid and a service provider without getting any benefit at all from the medical aid provider.

    Exploiting the poor even further!

    There is something very concerning about the mathematical abilities of our government, specifically when it comes to fiscal competence and statistical insights.

  • Wendy Webb

    “The regulations, which were demarcated in terms of the Long-term and
    Short-Term Insurance Acts, will come into effect as of 1 April 2017 for
    new policies and retrospectively from January 2018 for existing

    What’s retrospective about it?

  • Discus

    this is so stupid….limiting the GAP cover??!? WTF?
    The only reason we have this thing called “GAP cover” is because medical aids don’t pay the full amount and then we have to pay the difference….
    having GAP cover protects us from paying the difference… IT DOES NOT@#$#@$ STOP DOCTORS AND HOSPITALS FROM CHARGING US A FORTUNE !!
    so why the @#$#@ will limiting GAP cover stop them from charging a fortune???

    I swear these ANC morons that make up new policies are brain dead!

    • Jacobus Pienaars

      Yep. The doctors will merrily go on charging as they like and you and I will go on paying it because the alternative is in fact dying.

      • Thinus

        Why would they do that when the incentive not to do so comes from the medical schemes? The whole reason for the changes is to force people to take more expensive cover.

    • Drikus Theron

      Actually you are wrong when it comes to why we have Gap cover. If your GP is charging more than the medical aid rate, it is because he is taking advantage of you. I suggest getting a new GP. The whole point is to force doctors to move their rates down so it is in line with medical aid benefits. Gap cover should only come into play when you medical aid benefits have been dried up, e.g. you have exceeded the number of allowed GP visits, hospitals stays etc.

      Our first Genea was charging almost double the medical aid rate because she was working out of offices in a newly built Medi Clinic, so we simply went to a different Medi Clinic were the doctors and specialists were all in line with medical aid prices. Not only did we get the same treatment, but arguably better. When are we going to open our eyes and see that doctors in this country are taken advantage of us, because we are to scared to go to an alternative option.

      research your GP and the prices they charge, there is always an option to go to someone that only charge medical aid rates.

      Your medical aid pays exactly the amount that is fair in relation to the treatment, the doctors are the thieves in this scenario. I’m just glad our government for once got something right. This will force doctors to lower prices and will cause a lot more low cost Medical aids to become available.

      • Rick Grimes

        Gap cover is not for GPs! You’ve got it all arse about face, Drikus. This Marxist theory of yours (and our government) is a Utopian dream, and has been disproven time and again! Medical aid does NOT pay out fair amounts. Not by a LONG shot.

        Besides, most of the time you need a specialist is when an emergency hits, and you don’t have the luxury of choice. When I broke my thumb at its base, I had to see a bone-specialist immediately. I needed surgery that same week to re-attach it. He charged 400% the medical aid rate. I had no choice.

        • ElegantPotato

          The thing that really brought it home to me was the fact that my specialist charged different rates depending on whether I pay cash or by medical aid, and different rates depending on which medical aid I am with.

          Sometimes the doctors abuse a situation (like yours, because you have no choice). So by limiting the Gap cover available, the doctor is limited in what he can charge. It is much easier for him to believe he is smoking a corporation than the patient he is caring for.

          The ideal situation would be where you are not allowed to disclose to a doctor whether you have medical aid or not. That way he has to assume there is a chance you don’t and he charges the fair price for his services.

      • Discus

        The “medical aid” rates are absolutely pathetic in some instances. They make up a price and decide what they will pay … not based on real cost… not based on bench-marking… ithe proof of this is that these “approved rates” do indeed vary from medical aid to medical aid and also increase based on the type of cover you choose !

    • Tony

      Exactly …. what kind of fools think this is in our best interest. Once again, they take advantage of the patient …. sucking them dry for the next heist.

  • the-TRUTH

    Since re-joining a medical scheme 8 years ago, I cancelled all my short-term health policies, e.g. hospital plan, etc and at least I have successfully claimed in the past

  • Olives_21

    They must stop interfering with things that work n deliver text books on time

  • bengine

    “as doctors cannot take “advantage” of you and your hospital bill”
    Not saying much for doctors is it?

    • Emil

      No, you must look at the slice of the cake which goes to doctors! The HOSPITALS eat the money. Not much is said against them! They operate at a “business levels” and different rules.

      • Jacobus Pienaars

        “They operate at a “business levels” and different rules.” – Just asking… you going socialist here, then?

      • bengine

        The hospitals are a whole different story but there are some doctors out there that are getting out of hand – and the recent case Genesis lost where they were forced to pay out above the rates they stipulate in their rules has opened up a big can of worms – which we are all going to end up paying for.
        I exclude my GP from the above – he charges a decent rate and is a top class doctor – don’t begrudge him a cent.

  • AndrewWheelerDealer

    I wish they would consider the root cause of some of these problems. My wife’s gynaecologist will have to pay over R1 million Rand for medical practice insurance. That’s over R80,000 per month. They need to recoup that money from somewhere…

    • Chris

      Doctors over charge but a huge amount. We have a local doctor, and for tablets and consultation he charges R250 max.

    • Emil

      Yeah, just think this amounts to R800 000+ for 10 y period. No wonder Gyne’s have decided not to do confinements & caeserians any more. This 800grand is a money that could have been invested with good returns. Time to perform some other occupation!

      • Jacobus Pienaars

        But how much do they charge for a visit? And how many visits do they get? I bet the bankruptcy rate under gynecologists are very low.

      • Surveyor General

        Yip, they do have many other vocational callings, viz. becoming a car mechanic as they could easily overhaul a vehicle’s engine through the exhaust pipe whilst still charging the customer for the removal of the engine to do the job. Both disciplines flaunt high levels of ethics, however in real life their actions demonstrate that they both lack integrity!!!!

  • AndrewWheelerDealer

    1 April 2017? April fool?

  • I bet your premiums wouldn’t decrease just because you’re getting less for your money, by law.

    And when private services are forced to fall in line with new legislated price “fixing” they’ll start seeking better prospects elsewhere. Just because government isn’t able to get its services to run efficiently and effectively and to cater for the average Joe Citizen it shouldn’t assume that it can force private enterprise into doing its bidding, unless government plans to subsidize the private enterprise or is prepared to watch that private enterprise emigrate.

  • Chris

    Why is it that I can insure my vehicle for R500 000 at R700 per month, but for medical aid I need to pay R5000 for just me. I never use my medical aid and it is for me R5000 down the drain each and every month.

    • Jacobus Pienaars

      Wait for the day when you get ill. And we all get ill. Then you will see….. It then is die or find R200 000 quickly.

      • Tony

        It’s about enslavement of the masses and the eradication of the middle class.

      • Rick Grimes

        Exactly! Except now, you can’t even get that R200 000, because somehow it will be illegal. WTF

      • Name

        It is not that bad tho, Yes we read everyday horror stories at Government hospitals, But let me tell you, There are similar (not that many ..) at Private too. Just the Scale in the Government is much larger, They cater for maybe 80% of the 65Mil population..
        Friend of mine was diagnosed by GP with Mild pre heart attack condition..(He was complaining of short breath and pains..)
        He needed to see Cardiologist urgently or else.. GP asked which Medical aid are you on…
        Non ,My friend cant afford one even Basic Hospital Plan at R1700pm
        So the option only ,was Helen Joseph.
        He was admitted after an Hour waiting, Spend 2 weeks in the ward,
        Had been driven to some Scope Machine at Joburg Gen, with camera they observe his aorta and heart valves to assess if there was any damage already..
        He said they drive few guys early in the morning with ambulance,At Joburg Jen , the specialist told him that all Private hospitals come here for that Scopy thing because there is only one device in the town or country(not sure) , So Helen Joseph patients went first while Private clients waited.
        Long Story short, He spend 2 weeks in Government Hospital,
        He said apart from that the TV did not have Supersport , rest was not that bad,. Yep is not as Pampered as Olivedale or any in that mater Private hospital,
        But he paid Only couple of HUNDRED Rands and got on life long Blood Thinning Medications FOR FREE.
        He did not die and is better Off already.
        As I said there are lots of stories we read but at that massive population they care for… is quite , how to say.. understandable.
        Just Read manchestereveningnews(dot)co(dot)uk website and see how is in UK.
        Like I am reading Daily Sun in SA, They have similar issues..

        I am paying for Hospital Plan only (hardly visit GP, Ones in 2 years, Dentist is the most I pay for), And now I will pay +R3700 for 2 adults 2 kids. That I never use for last 20 years..

        • fantadevels

          Good point you are making. Simply because someone got a bad treatment from so and so hospital doesn’t mean the rest of the country is experiencing the same. Public hospitals does a decent job free of charge. It’s a fact that people who pay medical aid won’t admit because they don’t wanna acknowledge that they’re just throwing away their money.
          Some companies though subsidies their employees’ contributions which makes it a decent point of consolation.

          • Name

            There are lots of procedures that are off sourced by Private hospitals(clinics) to the State facilities because they don’t have the proper equipment, But the the Med Aid still pays Prime for that..
            I can’t speculate if the State facilities then charges the Private for using their equipment, Maybe yes ..
            My opinion is that the med Air scheme is just scare mongering for 10% of the population.. that can affords or like you said the Companies that contribute to their staff..

    • Surveyor General

      All because the medical aid scheme’s are effectively a multi-layer Ponzi scheme/ pyramid scheme, viz. 1.Medical Aid with its organogram of employees/ 2. Appoints an independent Administrator to do the job which of those already employed in “1”/ 3. In the Administrator appoints network healthcare providers, along with a myriad of other pyramids, viz. Optical Services, Dental Services, hospitals, etc.!!!! And heaven help you if you source services from a healthcare provider at a cheaper rate than those who appear on your medical aid’s approved network – you will end up having to make a 30% co-payment for the services you sourced at a cheaper rate !!! It all reminds me of the old “Boetie, Boetie, System” which prevailed in yesteryears but with a subtle difference – snout in the trough an corruption are the top priorities!

      • Tony


    • pieater

      Can’t you change your plan? You and I are obviously basically healthy, and should take the bare minimum. I pay R1,500 per month, plus R150 for Gap cover. I’m quite happy to pay for the occasional check up and doctor’s visit.

  • Danny Boy

    What’s happening with regulating doctors’ fees? This is the reason why we have gap cover. Limit gap cover, then it is out of pocket.

    Have any of these incredibly wise people ever visited a MediClinic??

    • Danie Maré

      Why should doctors’ fees be regulated? Is your salary regulated?

      Instead, why not force doctors to advertise their prices so you can shop around before you are sick and in dire need. Nothing will lower prices lime an empty waiting room.

      Then on the other hand, if we never leave a doctors rooms when you feel he/she is to expensive, will they ever reduce the fee

  • Jacobus Pienaars

    “In theory this should equate to you actually paying less as doctors cannot take “advantage” of you and your hospital bill.” – Have you heard the one about the mouse who told the meerkat that dogs can fly?

  • Helldriver Phoenix

    Our dumb Government at work. They should rather set limits, specialist and doctors may charge for their services.

    • Jacobus Pienaars

      Easier than that: Have the public hospitals operate at decent levels (not the dirty scandals most are today) and train more doctors. And if needs be, build more hospitals and medical schools. If the struggle was not at the lowest level about enough hospitals where the people can get decent health care, what the hell was it about then?
      The ANC is betraying the struggle big time with health and education.
      All they seem to have delivered is BMW’s for trade union bosses…..
      I actually support trade unions. But like anything else in life they can be the opposite of what they are supposed to be. SA today proves that one on many levels…

  • Aristophanes

    Isn’t this just the thin end of the wedge in destroying private medical aid and putting everybody into the National Health plan? They’ve managed in 22 years to destroy the public health system by their theft and incompetence and now they want to do the same to everything else! I’m off – these useless cadavers don’t have a freaking clue.

  • Runnin Bare

    Its time Govt initiated a restriction on PMB costs. Medical aids are forced to pay PMB’s by law and that’s where the specialists charge 300% and more. This could help bring down the medical aid contributions considerably. I know of 2 married specialists, no kids, they don’t even know what to do with all their money.

  • Charl van der Merwe

    We need regulation of private healthcare that ,at the moment, simply charges an amount they feel like.

    Not regulation of godamn gap cover,sigh.

  • Danie Maré

    Seperate what you pay from how you pay. Force doctors and hospitals to advertise prices (I accept the estimation part of things but be innovative).
    Economics 101:
    Price is determined by a Wiling Seller (doctor) and Willing Buyer (patient) – although a grudge buyer – in a Arms Length Transaction WITH PERFECT INFORMATION.
    Now, if you charge me some arbitrary % of some rate (medical scheme rate) which I di not have access to and you do not tell me that untill after consumption, how will I ever use my consumer power and walk away to a cheaper provider?
    And why is the rate ever relient on the manner of funding/payment is beyond me?

  • BrS

    Doctors in South Africa don’t know you have additional insurance unless you tell them, so are they really charging more because gap cover will pay the difference?

  • Lukas

    It’s the specialist that is the problem. Not so much the GP’s.
    Went to a ENT for sinus problems. He didn’t even get of his chair when i was in his office. Told him what is wrong and he send me for a ct scan. Came back he looked at the scan and gave me the same meds my GP gave me. And for that two 5min consultations he charged me R1500 each. R3000 for seeing me for 10min.
    And still have sinus problems.
    They shouldn’t regulate medical aids and gap cover. they should regulate doctors.
    If you don’t get better within 7 days the next consultant should be free of charge.
    Maybe doctors will do a better job at looking after you and not just give you a hand full of meds and hope you get better.

  • Johan Lewis Last

    All this stuff could have been avoided if the corrupt and inept government fixed the public health care system we all pay for.

  • Erlo Muhl

    To me the whole medical system in S.A. is based on a milking machine principal that milks the pockets of the public dry to the hilt. The oath all Doctors should take seems to be something that disappeared over the recent years, or is not taken seriously any more.

  • Hennie

    I have my own teeth plus a denture plate. A dentist removed one of my teeth and the denture had been fixed with a new false tooth. My medical aid does not pay for fixtures but had I wanted a brand new plate with the new tooth it would have paid it fully. Bizarre. And it is one of the so called best medical aids namely Bonitas. Now I sit with cost of having to pay for the fixture. I wonder if all medical aids have the same rules?

  • DumbSA

    lube up everyone, the government is going to stick it in a bit deeper.

  • Luna Moon

    270 prescribed minimum benefits?? I was under the impression its only 27

  • Thinus

    F*(k it when I die throw me on the side walk with a board containing all the medical aid schemes logos & the caption “These Ponzi schemes killed me” a couple of those showing up on the pavement, over breakfast & the morning paper should get their attention…

  • Discus

    So … just another perspective… instead of improving coverage, and quality of health for the masses on the government schemes….they instead come hit us on medical aid …. us private funded citizens whom government are not paying and subsidising …. and reduce and worsen our health care benefits !

  • Cutting Edge

    Try to be realistic about what medical costs are actually based on. If you want first world medical care than realize that it costs about the same as in in the first world. Most medicines, surgical items and prostheses (like artificial joints) are imported with dollar or euro related costs. The more government tries to control costs, they more they cause unexpected changes – every person with common sense sees these end results except the politicians.
    By trying to ban low cost medical aids, they simply drive more people out of the medical aid market -> back to state hospitals.
    It is laughable to think that limiting gap cover will reduce doctors charges. Doctors need to earn a living, if they charge at medical aid rates, they may as well emigrate or go into a state hospital – with easy hours, no incentive to work or provide an efficient service.
    If you crush the earning of doctors, you will soon get a national system that is slow, lazy, inefficient and provides a terrible service.
    Please realise that by far the biggest cost driver of medical costs is hospitals, and importation of medical items. Having your appendix out: easily R30000, Heart Bypass: R500 000, 6 weeks critical care in ICU: R 1million, Chemotherapy for certain cancers: R200 000 – R1 million per year. All very well complaining of high cost medical aids – it is an insurance for when you really need it!
    Also compare that cost of a visit to your GP to the cost of a visit to your hairdresser, electrician or plumber callout. Consider also that the doctor took at least 7 years to start earning an income.
    If you pay peanuts, you get monkeys.

    • Rick Grimes

      As I commented earlier, the public should file a class action lawsuit against govt if their own GAP cover is “not legally allowed” to pay for the procedures. The only thing that will stop ministers in their tracks is draining their own pockets.

  • Stealth_Za

    Lol instead of actually doing his work he introduces new legislation. Fix the damn public institutions and stop firing medical personnel to keep the money to yourselves cANCer. Corrupt thieves.

  • Rick Grimes

    Public Service Announcement: If you end up bankrupt, because your GAP cover would not pay out due to legislation, stand together, people! File a class action lawsuit against the ministry. With damages/cost.

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