Medical scheme, Health Insurance? What’s The Diffs?
Medical scheme cover and health insurance: what’s the difference?
Not everyone is aware of the considerable differences between medical scheme cover and health insurance products. Making this fairly common mistake can however prove costly as you may well run the risk of not having the appropriate health cover when you need it most. CompCare Medical Scheme Chief Executive Officer and Principal Officer, Josua Joubert explains some of the critical differences between the two.
The Demarcation Regulations, which came into effect on 1 April 2017, sought to clarify the boundaries between medical scheme cover and other forms of supplementary medical insurance and went some way towards achieving this. Nevertheless, some healthcare consumers can still quite understandably get confused between medical scheme benefits and insurance products.
It is important to note that medical schemes and insurance products are governed by different legislation: the Medical Schemes Act 131 of 1998 governing the medical aid sector, while insurance products are governed by the Short-Term Insurance Acts.
Prescribed Minimum Benefits
The confusion between medical scheme benefits and insurance products, such as hospital cash plans, means that health insurance products that fall outside of the Medical Scheme Act are often purchased. These products do not offer access to health cover provided by the Prescribed Minimum Benefits (PMBs) for 270 life-threatening conditions and 26 chronic conditions that medical aids are required to cover by law. PMBs require all medical schemes to cover the full costs of treating these illnesses, which include emergencies and the chronic conditions such as diabetes, coronary artery disease, hypertension, asthma, epilepsy and others. PMBs therefore assist in providing medical scheme members, and even those on hospital plans, with a critical level of protection and cover should they ever experience a healthcare calamity. It should be noted, however, that some medical scheme options might require that their members access treatment of chronic diseases from their medical provider networks of doctors and hospital.