Medical insurance policies vs medical aid schemes

What is a medical insurance policy, and how does it compare to a medical aid scheme?

Medical aid schemes are governed by the Medical Schemes Act and the Council for Medical Schemes. These schemes are required to comply with a strict set of rules and regulations, and guidelines have been put in place to ensure that they cover the treatment of a certain minimum set of medical conditions, in order to ensure that every medical scheme member receives medical scheme cover in the event of a genuine medical emergency.

That set of conditions is known as the Prescribed Minimum Benefits. In addition to the Prescribed Minimum Benefits, a medical scheme may include additional medical cover, depending on the scheme option that has been chosen by the scheme member. Owing to the regulatory framework that medical schemes must operate within, the monthly contributions that they charge scheme members is comparably higher than what is paid by medical insurance scheme members.

Medical insurance schemes are currently not governed by the Medical Schemes Act or the Council for Medical Schemes. As a result, medical insurance policies can generate their own lists of medical conditions that are covered by the insurer. Because medical insurers do not need to provide the same legislated cover as medical aid schemes, their products can be offered to members at a much lower monthly cost than that of medical aid scheme membership.

Some supporters argue that the lower cost of membership opens these medical insurance schemes up to those who would otherwise not be able to afford medical aid scheme membership, while critics of the medical insurance industry argue that these policies have restricted growth within the medical aid scheme market, and are partly to blame for an ageing medical scheme membership base and annual contribution increases above that of inflation.

At the beginning of 2017, Treasury published the final demarcation regulations which will provide a much tighter regulatory framework within which medical insurance policies must operate. Medical insurance policies that offer basic doctor’s visits, optometry, dentistry, and hospitalisation, must convert to low cost medical aid schemes within a two-year period.

How do these policies relate to ambulance service cover?

As a medical insurance policy is not governed by the Prescribed Minimum Benefits, there is no guarantee of payment to an EMS provider in the event of emergency medical treatment. In the event of a medical insurance policy member requiring emergency medical treatment, the patient or their next of kin must contact the emergency call centre of the insurance policy directly, and the call centre must assess whether the condition is one that is covered by the scheme, as well as decide which approved provider will be authorised and dispatched to assist the patient.

If an EMS provider undertakes to assist a patient on a medical insurance policy within the time prior to authorisation or dispatch by the call centre that is responsible for the policy’s emergency medical care decisions, then the EMS provider must understand that there is a strong chance that they may not be reimbursed for the treatment that was provided to the patient, and that the EMS provider will need to invoice the patient directly for such services.

It is of vital importance that EMS providers understand that there is a notable difference between medical schemes and medical insurers, and that even if you treat a medical insurance scheme member during a genuine and life-threatening emergency, payment on behalf of the patient is not guaranteed by the insurer. When receiving requests for assistance directly by members of medical insurance policies, it is always best to confirm which policy the patient is on and contact the insurer directly for authorisation as soon as possible once the name of the policy has been established. Patients should also be encouraged to contact their designated assistance call centre directly in order to ensure that ambulance transportation is authorised, instead of calling an ambulance service directly.

In an EMS setting, medical insurance policies are not always ideal if you can’t directly contact the call centre that is responsible for the management of the policy. With these risks in mind, EMS providers must have a policy in place regarding service provision to medical insurance scheme members, and must be aware that payment is not guaranteed and that the patient may need to be held liable when the insurer refuses liability.

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