Medical schemes, healthcare cover and patients

Elsabė Klinck aims to empower patients on their rights in the funding of healthcare with a series of articles. This first article covers the basics of medical schemes, healthcare cover and patients.

A complex environment

Funding for healthcare is a controversial issue. It can lead to friction between healthcare funding companies (medical schemes or healthcare insurers), providers (doctors, hospitals) and patients.

Because no person chooses to be ill, the buying of healthcare services is rarely done on a purely voluntary basis. It is mostly begrudgingly. Add to this the aspect that some healthcare interventions are life-saving, the moral arguments on equal access to healthcare and a conflict-free discussion appears virtually out of the question.

With the Minister of Health’s recent announcements on changes to the healthcare system and to medical schemes, debates on co-payments have also been added to the above complexity.

The Health Market Inquiry has also found that patients find medical scheme options, benefits and the limitations thereto, daunting. Fighting for cover is also a difficult undertaking. Many patients simply give up, even if they feel they should have better cover.

The law as a patient’s guide

The legal frameworks do, however, protect patients, and the fund from which healthcare is paid. Understanding these frameworks will help patients, providers and funders to better communicate. They can then use the same reference points when discussing access to, or denial, of care.

Funding for healthcare services (doctors’ fees, hospitalisation, etc.) and goods (medicines, etc.) can be provided by:
  • Persons out of their own pocket (often these patients are called private patients);
  • Their medical scheme, subject to the provisions of the medical schemes law and the scheme rules;
  • Third party insurers, which sometimes provide lump sum cover for “dread disease” and/or “hospitalisation” or “gap cover”. These pay the difference between what another funder pays and what is owed.

Where third party funders (i.e. medical schemes or health insurers) pay healthcare services in part, co-payments may have to be paid by patients, to ensure that the full event, medicine or care is covered. In some cases, schemes call this levy a “penalty co-payments”. We will look at co-payments in the next articles of this series.

Knowing about the care you require

Whether funders would fund care or not, your healthcare journey must start with your healthcare professional (doctor, pharmacist, nursing professional, etc.) discussing your healthcare status with you. This includes how you feel, what they observe, and what the test results or physical examinations show them about your health.

Based on your healthcare status, your healthcare professional will discuss with you what your treatment options are, and what the benefits, risks and costs of each option will be. Regarding this, you must consider the arrangement of your funder.  Remember your funder makes rules for the general patient population under their cover. So, what they may fund, may not be what is appropriate for you.

Discuss the alternatives that your scheme will fund with your healthcare professional. Ask them to explain why you may require something your funder may not fund in full, or may not fund at all.

The same applies when you present a prescription at a pharmacy. Pharmacists must substitute products with generic alternatives. Ask the pharmacist if the product is substituted with another product. If you are uncertain, call your prescribing healthcare professional.

PMB conditions

For prescribed minimum benefit (PMB) conditions (we will address PMB in detail later), you are entitled to decline a product that would have been appropriate for you, in favour of something you choose voluntarily. But then there may be a co-payment levied. Some patients prefer to stick to treatment they know, or products they choose. Because of this choice, they will then only be reimbursed by the funder up to the price of the funder’s preferred product.

Right to decline care

You always have the right to decline care. For example, some patients do not want to co-pay, or they agree to swop treatment to what the funder is willing to reimburse. If a patient does this, she/he must understand what the implications (health and cost) of the refusal of care their healthcare professional advised is.

Ask your healthcare professional to explain why they would prefer or recommend a treatment that your funder does not pay for at all, or only pays for in part.

The medical schemes law states that a healthcare professional may never be incentivised to provide you with care that is inappropriate for you. It is therefore unlawful. For example, if your healthcare professional prescribes or dispenses a product because if they do so, they will get paid better by the funder, and such change is not in your interest.

Consumer legislation also prohibits any consumer (patient in this case) from being pressurised into accepting any service or goods. Therefore, take time when deciding on the right care for you, and consider the funding implications of the care you choose.

Paying for care

Medical schemes should, by law, pay for all conditions that are listed in the law as PMB conditions. There are 271 conditions listed in the law, and 25 chronic conditions.

Diabetes, its diagnoses, monitoring (e.g. through glucometers), and all treatment of (for example, diabetes-associated events, such as diabetic ‘highs’ or ‘lows’ where one lands in hospital) are included in the PMB.

The law says that this treatment must be funded “in full and without co-payment” (regulation 8, Medical Schemes Act). This, in short, means that the scheme must pay for all the care associated with living with diabetes.

Where a medical scheme limits the various aspects of healthcare, such as where you receive in-hospital care, or the medicine it would pay for, these limitations should take place within what the law allows. (We will go into the details of these circumstances on managed care, PMB, designated providers (DSP), etc. in future articles.)

 Medical scheme options or plans

Irrespective of your medical scheme plan or option, you are always entitled to appropriate care. Some scheme options do, however, limit the number of visits to healthcare professionals, limit your choice of hospital, or restrict the list of medicines from which your doctor may prescribe.

Normally, if you want more choices, you would have to belong to a higher option with a higher monthly contribution.

One should keep in mind that even if one is on a lower option, there may be circumstances where the law requires the full funding of care, not generally included in that option. For instance, circumstances that are outside of the control of the patient, such as a negative reaction to a medicine, or an emergency.

Where to seek help

Most medical schemes do have internal complaints and appeals systems. If you, as the patient and scheme beneficiary, do not come right at the scheme, you are entitled to lodge a complaint at the Council for Medical Schemes (CMS) – [email protected].

You should receive a case number within 48 hours. You will use that case number when communicating with the CMS. It’s important to include all information and dates, as well as any reports from your doctor, test results, how you were feeling or what you experienced, etc.

Do not forget to add that you have a PMB condition if that is the case. Also explain any instances where treatment was not successful, or where you had to switch treatments, and why that was the case.

Attach any reports or evidence of negative reactions or implications you have experienced to the complaint. Number all the attachments to your complaint and refer to each attachment by that number in your complaint letter.

If a ruling on a complaint is not in your favour, you can appeal that ruling. The details of this right, and the correct email address is always provided on the letter containing the ruling on your complaint.

Final thought

Patients should be aware of their entitlements in terms of the law. These entitlements override the medical scheme rules, if there is a conflict between the rules and the law.

The process starts with informed consent at your healthcare professional where your condition and the treatment options must be discussed.

You must consider the financial implications of your chosen care, or of the care that is necessary for you. Plan for your interaction with your funder, if you know they may not pay in full, or may not pay at all.

Ask your doctor for assistance to understand why you need a particular treatment, or why it may be good for you to choose a particular treatment freely.


Elsabė Klinck (B.Iuris, LLB, BA Hons (German), BA Applied Psychology) specialises in health law, -policy and -ethics. She owns a successful healthcare consulting firm, serving various clients in the pharmaceutical, medical device, healthcare professional and health facility markets.