The Board of Healthcare Funders (BHF) has taken the legal route in their bid to make low-cost medical scheme benefit options a reality for South Africans. 

In the line of fire is the Council for Medical Schemes (CMS), which the BHF believes, has failed to regularly review prescribed minimum benefits (PMBs). This continues to render private healthcare inaccessible and unaffordable for millions.

The representative body hopes the Pretoria High Court in Gauteng will overturn the CMS moratorium that effectively prohibits schemes from providing low-cost benefits options (LCBOs).

Aim of court action

According to BHF’s Head of Research, Charlton Murove, the court action seeks to compel the regulator to provide exemptions for medical schemes. 

“It then also wants the CMS to follow through with the demarcation regulations which were promulgated in 2017. Essentially, these regulations will mean that LCBOs will be offered through regulations as opposed to through exemptions,” stated Murove. 

Millions set to benefit

Murove stated that should they be allowed to offer low-cost benefit options, over 20 to 25% of the South African population is set to benefit. It’s estimated that up to 20 million low-income South Africans could afford basic private healthcare services if CMS can develop and amend a framework for low-cost benefits options.

“If this exemption is granted, it will also help assist the public sector. Those covered through this exemption will also be able to receive at least primary health care in the private sector. As a result, some of the pressures will be alleviated,” said Murove.

Statistics South Africa (Stats SA) states that 28,2% of the population turn to a private healthcare provider first when they need care.

Lifting the burden

According to BHF managing director, Dr Katlego Mothudi, the court application is informed by BHF’s realisation that millions of low-income earners, who would otherwise afford private healthcare, are being denied access to healthcare services because of the prohibitive cost of membership in a medical scheme.

“Currently, the state is overburdened and premiums for medical schemes are becoming unaffordable. This is rendered inaccessible by the mandatory prescribed minimum benefits (PMBs), which are a set of defined minimum health services that all medical scheme members are supposed to have regardless of the benefit option they have selected,” said Mothudi.

He continued: “The BHF has also previously expressed concern over the slow pace of reviewing the PMBs regulations by the CMS. The proposed solution seeks to pull towards the principles of Universal Health Coverage (UHC) to ensure that it leaves no one behind”.

Mothudi also stated that the application seeks to push forward a progressive agenda for the public and private healthcare sectors to work collaboratively. 

The BHF reiterates that all parties should work together in preparation for the implementation of UHC through the proposed National Health Insurance (NHI). 

CMS reluctance ‘unjust’

“The reluctance on the part of CMS to amend regulations governing LCBOs is inherently unjust. Many people who may afford some form of medical cover by defraying certain expenses, are deprived of the opportunity to do so,” added Mothudi.

Interests of people must be considered

According to Murove, it is also concerning that insurance companies are offering health insurance products (through exemptions from the CMS) like LCBOs while medical schemes are prohibited from offering similar benefits. 

“This has been the case since before 2016, at which time the CMS was tasked to structure a framework to allow medical schemes to do so, after the promulgation of the Demarcation regulations,” said Murove.

He further added. “The interests of the people must be considered and promoted, and this is what this court action seeks to achieve. The court order will promote the promulgation of policies that will enhance access to quality healthcare instead of the current policies that hinder it”. – Health-e News