Prescribed minimum benefits on medical aid, explained

Prescribed minimum benefits are the diagnosis, treatment and care costs that every medical scheme benefit option must pay in full, without co-payments or deductibles. They cover the conditions listed in Annexure A to the Regulations under the Medical Schemes Act, and any emergency medical condition. The scheme can still set rules about where you get treated.

Olvian is a lead-referral service, not a scheme, broker or adviser. This guide explains the rule so you can ask the registered broker or medical scheme that calls you sensible questions.

What are prescribed minimum benefits?

Section 29(1)(o) of the Medical Schemes Act says a scheme's rules must provide for "the scope and level of minimum benefits that are to be available to beneficiaries as may be prescribed". Section 67(1)(g) lets the Minister make regulations on that scope and level.

Regulation 7 does the prescribing. It says prescribed minimum benefits "consist of the provision of the diagnosis, treatment and care costs of":

• the Diagnosis and Treatment Pairs listed in Annexure A, subject to any limitations specified in Annexure A; and
• any emergency medical condition.

A "prescribed minimum benefit condition" is a condition in one of those pairs, or any emergency medical condition. A diagnosis and treatment pair links a condition to the treatment the Regulations say must be covered.

Which conditions are on the list?

Annexure A to the Regulations sets them out, pair by pair, with explanatory notes. The list is long and technical, and it is amended from time to time, so a general guide like this one cannot reproduce it. Ask the scheme to show you the entry for a condition you are asking about, and check the current annexure on the Council for Medical Schemes' website.

A condition being named is not always enough on its own. Annexure A attaches limits to some entries, which is why the definition says the pairs apply "subject to any limitations specified in Annexure A".

What does "pay in full" mean?

Regulation 8(1) says that, subject to the rest of the regulation, any benefit option offered by a medical scheme "must pay in full, without co-payment or the use of deductibles, the diagnosis, treatment and care costs of the prescribed minimum benefit conditions".

Two points follow.

• The duty applies to every benefit option, including the lower-priced ones. An option cannot be sold without it.
• It is about those conditions and their treatment as defined in Annexure A. It does not mean a scheme pays for every treatment of every illness, and it does not remove other limits on benefits outside the prescribed list.

Regulation 9 supports the same idea from another side. A scheme may cut a new member's annual benefits pro rata in the year they join, "with the exception of the prescribed minimum benefits".

Can a scheme tell me where to be treated?

Yes, within limits. Regulation 8(2) lets a scheme's rules provide that these costs are paid in full only if the services come from a designated service provider, which regulation 7 defines as a provider or group of providers chosen by the scheme as the preferred provider for one or more prescribed minimum benefit conditions. Rules may also impose a stated co-payment or deductible if you use a different provider by choice.

The same regulation protects you when the choice was not really yours. No co-payment or deductible is payable if the service was involuntarily obtained from a provider other than the designated one. Regulation 8(3) says that is deemed to be the case if:

• the service was not available from the designated provider, or would not be provided without unreasonable delay;
• immediate medical or surgical treatment was needed in circumstances or at locations that reasonably prevented you from using a designated provider; or
• there was no designated provider within reasonable proximity of your ordinary place of business or home.

Regulation 8(4) adds that schemes may still use tools such as pre-authorisation, treatment protocols and formularies. Under regulation 8(5), if a formulary includes a clinically appropriate and effective drug for a prescribed minimum benefit condition and you knowingly decline it in favour of another, the scheme may impose a co-payment.

How are emergencies treated?

Regulation 7 defines an emergency medical condition as "the sudden and, at the time, unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person's life in serious jeopardy".

Every emergency medical condition is a prescribed minimum benefit condition, whether or not it appears in Annexure A. Regulation 8(6) goes further: a scheme may not prohibit, or enter into an arrangement or contract that prohibits, a health care provider from starting an appropriate intervention before receiving authorisation from the scheme or any other party.

Whether a particular event meets the definition is a clinical and factual question. The scheme and your treating provider decide first, and the dispute route below is open if you disagree.

Do waiting periods apply to prescribed minimum benefits?

Partly, according to the wording of section 29A of the Act. Subsections (2)(a) and (3) say that when a person has had previous scheme cover ending less than 90 days before applying, the waiting period does not extend to "any treatment or diagnostic procedures covered within the prescribed minimum benefits". Subsection (1), for someone with no scheme in the previous 90 days, does not carry those words. Our guide on medical aid waiting periods goes through each case. Ask the scheme in writing how it applies the rule to you.

What if a scheme will not pay?

Start in writing with the scheme and use its internal dispute process. The Council for Medical Schemes asks complainants to do that before they come to it.

Section 47 of the Act then provides for a written complaint to the Council, which asks the other party to comment within 30 days (or a longer period the Registrar allows) and then resolves the matter or takes it to the Council. Section 48 lets a person aggrieved by a decision on a complaint appeal to the Council by affidavit, within three months of the decision unless the Council allows longer for good cause.

When you complain, say which prescribed minimum benefit condition you rely on, which regulation 8 provision applies, and attach the scheme's refusal.

What should I ask the scheme or broker who calls me?

Olvian does not advise on which scheme or option suits anyone. These are factual questions they can answer:

1. Which providers are your designated service providers for the conditions I am worried about, and how do I find them?
2. Is there a co-payment if I choose a different provider voluntarily?
3. How do you treat prescribed minimum benefit conditions during a waiting period?
4. What is your process for emergency admissions, and who do I call?
5. Where do I find the Annexure A entry for the condition in question?

Sources

• Regulations made under the Medical Schemes Act 131 of 1998, regulations 7, 8 and 9 and Annexure A, as consolidated and published by the Council for Medical Schemes. https://www.medicalschemes.com/files/Acts%20and%20Regulations/MSREGS19July2004.pdf
• Medical Schemes Act 131 of 1998, as consolidated by the Council for Medical Schemes: sections 29(1)(o), 29A, 47, 48 and 67(1)(g). https://www.medicalschemes.com/files/Acts%20and%20Regulations/MSACT19DEC2003.pdf
• Council for Medical Schemes, the complaints procedure. https://www.medicalschemes.co.za/consumer-assistance/complaintsprocedure/

The Regulations and Annexure A are amended from time to time, and the consolidation linked above is the one the Council published. Check the current text on the Council's website before relying on a particular entry.