Johannesburg – There was no immediate clarity in a dispute over how much medical aid schemes are obliged to pay in terms of prescribed minimum benefits (PMB) after the High Court in Johannesburg postponed an application on the matter on Wednesday.
The Board of Healthcare Funders (BHF), which represents medical schemes, had wanted the court to place an interdict on a circular from the Council for Medical Schemes (CMS) warning them that if schemes did not pay the full amounts in bills submitted to them in terms of the PMB, they would face punitive measures.
PMBs are a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected, according to the CMS, the regulatory body for medical schemes.
Medical schemes have to cover the costs related to the diagnosis, treatment and care of any emergency medical condition, a limited set of 270 medical conditions and 25 chronic conditions.
The dispute centres on the words “pay in full” in Regulation 8 (1) of the General Regulations in terms of the Medical Schemes Act, because the BHF and the CMS interpret them differently.
The BHF believes the regulation means that medical schemes are compelled to pay in full for PMBs up to what is stated in the rules of the individual scheme. The CMS interpretation, conversely, states that medical schemes are compelled to pay in full at whatever price the healthcare provider charges, a statement from BHF explained.
It wanted the court on Wednesday to place an interdict on the CMS circular so that it cannot execute the punitive measures it refers to.
It would then follow this up by asking the court for a declaratory order on what “pay in full” means.
However, at the eleventh hour numerous parties launched applications to intervene, said BHF spokesperson Heidi Kruger, and so the matter was postponed.
Final papers for the declaratory order are now expected to be filed by the end of January and answering papers by the CMS by the end of February.
They will then apply to the judge president for a date for their hearing.
“It is BHF’s view that the CMS interpretation is causing the industry to be unsustainable and pushes up the cost of medical scheme premiums to the consumer,” Kruger said.
The scrapping of the Reference Price List (RPL) in July and the Health Professions Council of SA’s Ethical Price List has also left the industry with no tariff guidelines.
PMB services are usually hospital or specialist services and there is currently no cap on what they can charge, with some going 300% more than the amounts on the old RPL, the statement said.
The pool of funds available for members could be threatened and costs could go up for medical aid members if the scheme was forced to pay whatever a service provider charged.
The CMS could not immediately comment on the matter.