Regulator to tackle ‘undesirable’ medical aid co-payments in South Africa

The Council for Medical Schemes (CMS) has flagged co-payments as an ‘undesirable practice’ and plans to introduce regulations in the coming months to curb the practice.

Under current CMS regulations, South Africans may need to pay more for a particular treatment or medicine if it falls outside of the plan coverage on a given medical scheme.

This is known as a co-payment, which is the amount that you must pay from your own pocket for a particular treatment or procedure as determined by your medical aid scheme.

Medical members are often also asked to pay co-payments if they opt to visit a specialist or hospital if they have not been selected as a ‘dedicated service provider’ (DSP). This is commonly referred to as paying ‘out-of-network’.

In a government gazette published at the end of April, the CMS said that this system is problematic as schemes are able to unilaterally – without restriction – determine the criteria to apply when selecting their DSPs.

This unfairly limits the number of selected service providers, including pharmacies, available to provide healthcare services to the members.

Members are also effectively forced to use only the selected limited number of DSPs or risk paying exorbitant co-payments.

To address these and other co-payment related issues, the CMS said that it will publish new guidelines on co-payments within the next 180 days.

According to the Council for Medical Schemes (CMS), there are about 4.05 million registered members of different medical schemes, serving a total of 8.94 million beneficiaries. This is about one in six of South Africa’s population of nearly 60 million.

The largest scheme by some margin is Discovery Health, which has 1.342 million members (33% of the total) and 2.795 million beneficiaries (31% of the total).

Among the open schemes, Discovery is followed by Bonitas, with 336,651 members and 718,919 beneficiaries, and Momentum Health, with 156,841 members and 298,829 beneficiaries.

However, including restricted schemes, the second largest medical scheme overall is the Government Employees Medical Scheme (GEMS), which has 713,646 members and 1.856 million beneficiaries.

The South African Police Service Medical Scheme (Polmed) is also in the top five, with 177,430 members and 507,217 beneficiaries.

Read: South Africa prepares for next phase of the NHI – which includes ‘mandatory pre-payment’

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Regulator to tackle ‘undesirable’ medical aid co-payments in South Africa