South Africa CMS: PMB Reform Underway for Medical Schemes

• The Council for Medical Schemes (CMS) is undertaking a major review of Prescribed Minimum Benefits (PMBs) for medical aids in South Africa.
• The Medical Schemes Act mandates biennial PMB reviews, but a full overhaul has not been completed despite additions like HIV and Covid-19.
• A previous PMB reform proposal was rejected by the Minister of Health due to its hospital-centric focus, prompting a directive for a primary healthcare package.
• The CMS is now developing a primary healthcare package for PMB inclusion, aiming to balance comprehensive coverage with affordability concerns.
• The reform seeks to manage costs while increasing medical scheme member coverage, particularly for conditions leading to catastrophic health expenditure.

The overarching goal of the reform is to manage the costs of the revised PMBs effectively while simultaneously broadening access and increasing the overall coverage for medical scheme members.

The Council for Medical Schemes (CMS) in South Africa has embarked on a comprehensive review of Prescribed Minimum Benefits (PMBs) for medical aids. This significant undertaking aims to redefine which medical conditions and treatments should be classified as PMBs and to optimize how these benefits serve medical scheme members across the country. The initiative represents a critical effort to adapt mandatory healthcare coverage to evolving medical needs and technological advancements.

While the Medical Schemes Act stipulates that PMBs should undergo a review every two years, a complete overhaul of the existing framework has not been achieved to date. Despite this, ongoing progress has been made in assessing and updating specific conditions covered under PMBs, reflecting advancements in health technologies, including newer medications and treatments. Notable additions to the PMB list over time have included various chronic disease conditions, HIV many years ago, and more recently, Covid-19.

The legislative framework governing medical schemes, specifically the Medical Schemes Act, mandates the regular assessment of prescribed minimum benefits. The review process is a complex, multi-stakeholder endeavor, with the National Department of Health and the CMS jointly leading the activities. Ultimately, any recommendations arising from the PMB review require the approval of the Minister of Health.

A previous attempt to reform the PMBs saw a reviewed package submitted to the Minister for endorsement. However, this proposal was not approved, primarily due to its predominantly hospital-centric nature. Following this decision, the Minister provided guidance to the CMS, directing the council to focus on developing a primary healthcare package of services that could be integrated into the prescribed minimum benefits framework. This directive has since guided the CMS's ongoing work in this area.

A central challenge identified with the current PMB structure is its strong emphasis on hospital-based care, often at the expense of comprehensive primary healthcare services. In response to the Minister's guidance, the CMS is actively engaged in developing a primary healthcare package, aiming to incorporate these essential services into the revised PMBs. This work is pivotal in moving towards a more balanced and holistic coverage model for medical scheme members.

However, expanding prescribed minimum benefits inevitably raises concerns about potential increases in the minimum cost of medical scheme coverage, which could exacerbate existing affordability issues for many South Africans. The CMS acknowledges this delicate balance, striving to design an ideal package that encompasses both primary healthcare and coverage for common PMB conditions, particularly those that can lead to catastrophic health expenditure. The overarching goal of the reform is to manage the costs of the revised PMBs effectively while simultaneously broadening access and increasing the overall coverage for medical scheme members.

Lawyers advising medical schemes, healthcare providers, or corporate clients on employee benefits should closely monitor the Council for Medical Schemes' ongoing review of Prescribed Minimum Benefits. This reform could significantly alter mandatory coverage requirements, particularly with the proposed inclusion of a primary healthcare package, necessitating adjustments to scheme offerings and compliance strategies.

Source: Original reporting via Moneyweb