• Currently, some medical schemes demand large co-payments if members don’t use their designated group of doctors, pharmacists or hospitals.
  • But the Registrar of Medical Schemes has gazetted a new notice, indicating that these co-payments will be limited in coming months. 
  • Also, medical schemes will have to follow new rules in deciding who can be designated service providers.

A crackdown is coming on the large co-payments that some medical schemes demand if members don’t use their designated group of doctors, pharmacists or hospitals.

Currently, many members are forced to use only a selected, limited number of service providers or risk paying “exorbitant” co-payments, the Council for Medical Schemes (CMS) says.

But in a new notice published in the government gazette, the Registrar of Medical Schemes announced that some of these practices are now “undesirable” – including “co-payments which are unfair to members or beneficiaries or cannot otherwise be numerically justified”.  Medical schemes won’t be allowed to charge a co-payment “that exceeds the quantum of the difference between that charged by the medical scheme’s designated service provider and that charged by a provider that is not a designated service provider of such scheme.”

The CMS will publish new guidelines on co-payments within the new few months.

In addition, medical schemes must prove that they were “fair, equitable, transparent, competitive and cost effective” in their selection of preferred providers for the diagnosis, treatment, and care of prescribed minimum benefit conditions. New guidelines on selecting designated service providers will also be published in coming months.

The CMS says some medical schemes currently “unilaterally” determine criteria when selecting their dedicated service providers, without engaging in a fair procurement process and without considering applications from all qualified service providers.

“(This) unfairly limits the number of selected service providers [including pharmacies] available to provide healthcare services to the members.”

According to the CMS, this has prevented many healthcare service providers, including independent community pharmacies, to join scheme’s designated networks – even though they are willing and able to provide healthcare services at the same fee rate as the selected services providers.

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