The Medical Aid Act - The Ultimate Guide
The Medical Aid Act Ultimate Guide in South Africa revealed.
We tested them side by side and verified the best guide to the medical aid act.
This is a complete guide to the medical aid act in South Africa.
In this in-depth guide you’ll learn:
- What is the medical aid act?
- What does the medical aid act protect?
- What are the medical aid scheme regulations?
- What is the Council for medical aid schemes?
So if you’re ready to go “all in” with the medical aid act in South Africa, this guide is for you.
Let’s dive right in…
The Medical Aid Act – The Ultimate Guide
All medical aid plans in South Africa must be listed with the Council for Medical Schemes. The Council for Medical Schemes is a government agency that was set up by the Medical Schemes Act 131 of 1998. It is in charge of regulating how private health care is paid for through medical plans.
In South Africa, there are close to 100 approved medical aid schemes that contribute more than R84 billion each year. This is an industry that needs to follow the rules and guidelines of the Medical Schemes Act at all times to make sure that members of all medical aid schemes get good medical care.
What is the Medical Aid Act
The Medical Schemes Act brings together all of the rules about registered medical help schemes. It also says who the Registrar of Medical Schemes will be.
This Act protects the rights of people who are part of medical plans and gives plans ways to work together. This is a way to protect the people who belong to medical schemes and to give all medical help agents a set of rules to follow. When you join a medical aid or work with a broker, you should make sure they are registered with the Council for Medical Schemes.
Members of all medical aids can be sure that they will be treated fairly and in line with the law if they follow the rules set out in the Medical Schemes Act. This is important because a member can complain to the Council for Medical Schemes if he or she is treated unfairly.
The case will be looked into, and if it turns out that the medical plan did business in a way that was against the law, they could get a big fine or even lose their licence if it was a major crime. This makes sure that all medical aids follow the law and always act in a way that is consistent with the rules and guidelines that govern them.
The Medical Schemes Act covers things like how to sign up for a medical help, how claims are handled, what paperwork is needed to sign up a new member, and how audits are done.
What is the purpose of the Medical Aid Act
Private health care, through medical aid schemes, is governed under the Medical Schemes Act of 1998. By regulating and overseeing the actions of businesses that provide medical help, its main goals are:
- to safeguard the interests of individuals who are participants in medical assistance programmes.
- to provide for the establishment of the Council for Medical Schemes as a juristic person;
- to provide for the appointment of the Registrar of Medical Schemes;
- to make provision for the registration and control of certain activities of medical schemes;
- to protect the interests of members of medical schemes;
- to provide for measures for the co-ordination of medical schemes.
What are the main sections of the Medical Aid Act
The following extract from the Medical Aid Act describes the main sections to whom it is of relevance:
- Any person who falsely claims for the payment of any benefit under a medical aid scheme commits a criminal offence.
- Any person who knowingly submits some fact to a medical aid scheme, which will be used in determining his entitlement to a benefit, and which fact is false, commits a criminal offence.
- It is also an offence not to disclose information about an event, or occurrence (which will affect your right to receive any benefit) in order to obtain some benefit to which you would not otherwise be entitled.
- It is an offence to be a member of more than one medical scheme, or the dependent of more than one member.
- It is even a crime to claim or accept benefits from a scheme of which you are not a member.
B. Medical practitioners
- It is a crime to render a false statement, account or invoice knowing that it may be used by someone to claim any benefit from a medical aid scheme.
C. Medical aid schemes
- To carry on business as a medical scheme, you must be registered in terms of the Act. It is an offence to do otherwise.
- It is a crime to use a name for your business which is likely to give the impression that it is a medical aid scheme if you are not registered.
- It is also an offence to market, advertise, or promote your business in a way which is likely to create the impression that it is a medical aid scheme, unless you are registered.
- Advertising or promoting a medical aid scheme in a way likely to create the impression that membership depends upon buying some other product, benefit or service is forbidden, and it is an offence to do this.
- It is an offence for a medical scheme to carry on any business other than that of a medical scheme.
- No person may provide any service or advice concerning admission to a medical scheme, or its benefits or services unless he is accredited by the Council for Medical Schemes as a broker.
- A medical scheme may not compensate a broker other than by paying the prescribed commission, under the circumstances established by the Minister of Health in regulation, and it is an offence for it to do otherwise.
- It is also an offence for a broker to receive compensation for providing broker services other than from a medical scheme, a member (or prospective member) or his employer, or if he is employed by another broker.
- It is an offence for a medical scheme to use or refer to itself by a name other than the name under which it is registered.
READ more on How to Report a Medical Aid Scheme for Wrongdoing
What if a doctor or hospital does not follow the Medical Aid Act
You have the ability to file a complaint with the appropriate regulating authority if you believe that a doctor or hospital has violated the Medical Aid Act in any way.
In South Africa, this function is performed by either the Health Professions Council of South Africa or the Council for Medical Schemes. These institutions have the ability to examine the complaint, and if they discover that the doctor or hospital has violated the Act, they can take appropriate action.
Who governs medical aid in South Africa?
The Council for Medical Schemes governs medicalschemes in South Africa in accordance with the Medical Schemes Act 131 of 1998.
When was the Medical Aid Act introduced in South Africa?
The Medical Aid Act was presented by the Council for Medical Schemes to the Select Committee on Security and Constitutional Development after it was approved in 1988.
What is the aim of the Medical Schemes Act?
The Medical Schemes Act 1998 aims to govern private health care – in other words, medical aid schemes. It protects the interests of members of medical aid schemes by regulating and controlling the activities of medical aid companies.
What is Regulation 6 of the Medical Schemes Act?
Regulation 6 of the Medical Schemes Act Regulations states that, if a medical scheme decides that an account, statement or claim is erroneous or unacceptable for payment, both the member and the relevant health care provider must be informed within 30 days after receipt of such account.
Are members of medical aid schemes also protected by the Medical Aid Act?
Yes, the Act protects members of medical aid schemes as well as service providers.
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