Medical schemes: No more unfair penalty co-payments

No more unfair penalty co-payments will be allowed for medical schemes after the Council for Medical Schemes (CMS) declared this practice irregular and undesirable in terms of the Medical Schemes Act in a notice published in the Government Gazette.

Unfair penalty co-payments

The declaration comes after the Registrar of Medical Schemes received information that some medical schemes:

• Specify in their rules the substantial co-payments for pharmaceutical products which amount to penalty co-payments
• Calculate the penalty co-payments as a percentage of the total script dispensed which consists of the single exit price (cost price) of the medicine plus the dispensing fee rate of the service provider pharmacy, which unfairly penalises members who do not use the designated service provider.

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No more unfair penalty co-payments

The Registrar of Medical Schemes decided to, subject to written representations by interested people and with the concurrence of the CMS and the minister of health, declares these co-payments that exceed the difference between the amounts charged by the designated or non-designated service provider as undesirable. This also includes any other co-payments which are unfair to members or beneficiaries or cannot otherwise be numerically justified.

The CMS will publish guidelines on co-payments within 180 days.

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