KEY FOCUS AREAS
Our overarching objective is to advocate for a vibrant and sustainable private health sector within a well functioning and equitable health system.
Medical schemes and administrators continue to navigate an increasingly challenging environment. The population of medical scheme members has declined in real terms, driven by factors such as rising unemployment, emigration, and economic pressures. Prescribed Minimum Benefits (PMBs) are consuming an ever-larger portion of member contributions, straining the financial resources of schemes. Additionally, the industry is grappling with growing anti-selection and a significant rise in members with chronic diseases and mental health conditions. Regulatory uncertainty and an incomplete regulatory framework create additional pressures, making it difficult for schemes to plan and operate effectively.
These factors collectively underscore the need for robust advocacy, strategic interventions and a clear and unified voice to ensure the sustainability and resilience of the sector.
Strategic engagements with key policymakers are a primary focus. To this end, has nurtured a constructive relationship with the Registrar of Medical Schemes and signed an MOU with the Council for Medical Schemes, further strengthening this relationship.
Our current key focus areas include:
NHI
HFA continues to pursue a dual strategy of constructive engagement as well as a robust legal response to the NHI Act. Led by the NHI Steering Committee, HFA’s strategy is built on three key pillars: member communications and media, stakeholder engagement, and litigation.
HFA’s litigation strategy which is premised on substantive matters is led by ENSafrica, supported by a formidable legal team which includes Senior Counsels Adila Hassim and Wim Trengrove. Legal arguments are underpinned by thorough research being conducted by Genesis Analytics and supported by actuarial, economic and other expertise.
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LCBO
HFA continues to advocate for reforms that enable medical schemes to provide Low-Cost Benefit Options (LCBO). HFA has committed significant resources and expertise towards development of a LCBO as it recognises that the introduction of these options present an immediate opportunity to broaden primary care coverage and encourage innovation for the benefit of all.
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PMB Review
HFA is represented on the PMB Review Committee by two industry experts, Prof Roseanne Harris and Dr Boshoff Steenekamp. HFA is concerned at the the escalation in the cost of PMBs and is advocating for the review of the PMBs alongside the work being done on the development of a primary care package.
HFA has raised its concerns regarding a ‘service based’ list and to this end has made a submission on a finite primary care package.
HFA continues to advocate for a review of the current PMBs.
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PCR PRICING CASE
During 2022, HFA submitted a complaint to the Competition Commission against Pathcare, Ampath, and Lancet, over their pricing of COVID-19 PCR tests during the pandemic in 2020 and 2021. At the onset of the pandemic, a consensus was reached that these tests should be priced on a cost-recovery basis, with an initial agreement set at R850 per test, expected to decrease with reduced input costs. However, the laboratories did not adjust their prices downward despite significant cost reductions.
The HFA, representing 36 medical schemes and 5.6 million members, are seeking refunds for these excessive PCR test prices for the benefit of medical scheme members, underscoring the Medical Scheme Trustees' commitment to safeguarding members' interests and ensuring prudent financial management.
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IFRS 17
The transition year for IFRS 17 has allowed schemes to engage with the new standard and identify areas needing attention. After engagement with member schemes on their concerns and challenges with implementing IFRS, HFA requested a meeting with the Registrar on various issues relating to the new standard, including:
- Consistency between IFRS 17 and Statutory Returns
- Timing of the Annual Statutory Returns
- Audit fees
HFA is working with the CMS and the Medical Scheme Project Group of SAICA on proposed customisations to enhance the understandability of schemes’ AFS, enabling Boards of Trustees, members, and other stakeholders to make informed decisions.
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Fraud, Waste, and Abuse (FWA)
Tackling Fraud, Waste, and Abuse (FWA) is a core strategic priority for HFA in 2025. Recognising that FWA is an industry-wide challenge rather than a competitive issue, HFA is committed to taking a unified and proactive approach. To this end, we will be engaging our members in a collective initiative to actively address FWA, ensuring it is managed constructively and transparently for the benefit of all stakeholders. As a member of the FWA Advisory Committee, HFA has contributed to critical policy guidelines and has endorsed the FWA Charter, the HFA Code of Good Practice, and the SOP for fund recoveries from health service providers. Through these collaborative efforts, HFA seeks to foster an industry environment where FWA is rigorously managed for the benefit of the entire healthcare sector.
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Categorization of Assets, Regulation 30 (4) (iii) and (iv)
HFA is committed to advocating for a review of Regulation 30 (4) (iii) and (iv), which we believe could positively impact schemes’ investment income, creating a pathway to potentially reducing member contribution levels. HFA has already engaged with the Registrar on this matter and will continue to champion this review, confident that it will benefit both schemes and their members.
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DSP ‘Undesirable Business Practice’ Ruling Appeal
HFA and several member schemes are appealing the Registrar of Medical Schemes' decision to declare certain practices regarding Designated Service Providers (DSPs) and co-payments as "undesirable."
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RAF’s Directive on Payment of medical scheme member claims
HFA, and several of its member schemes supported the application by Discovery Health to compel the enforcement of the judgement compelling the RAF to pay claims while its appeal was being considered. This followed the successful court action which led to the RAF directive not to pay claims for medical scheme members, being declared unlawful.Please contactRAF Tariffs
In August 2022, Transport Minister Fikile Mbalula and the Road Accident Fund promulgated new, reduced medical tariffs for medical professionals in the private sector.
This followed representation and submissions made by HFA and others on the proposed tariffs. HFA’s input emphasised that the published tariff was significantly below that of the current tariffs and contained just 60% of the conditions currently pertaining in the private sector and, if instituted, could have a significant financial impact on schemes and set a worrying precedent.
The Law Society of South Africa (LSSA), along with the National Council for Persons with Disabilities (supported by HFA and others), legally challenged the RAF newly introduced medical tariffs, arguing they deny financially disadvantaged road accident victims access to private healthcare. These tariffs only cover costs below actual private healthcare rates, pushing victims to overburdened public hospitals. In December 2022, an interim interdict was granted to halt the tariffs until a full review could determine their lawfulness. The RAF attempted to appeal but faced repeated setbacks, including punitive cost orders and orders to disclose documents explaining the tariff decisions. The tariffs remain suspended pending final court review.
In a key development, a settlement agreement was reached in October 2024 between the Minister of Transport, the RAF, and the opposing parties. As part of this agreement, the RAF committed never to apply the disputed medical tariffs, leading to the withdrawal of the High Court case. Following this, the RAF published new draft replacement tariffs, which are a marked improvement over the previous rates.
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Several strategic initiatives to foster innovation, improve efficiencies, and enhance the healthcare journey for medical scheme members are on HFA’s radar. In addition to the above key focus areas, HFA is actively pursuing the following:
- HMI Recommendations and Value-Based Care (VBC):
- Tariff Standardisation: HFA will actively participate in the industry-wide effort to standardise coding for more streamlined billing and service tracking.
- High-Cost Therapies:
- Health Technology Assessment (HTA):
- Establishment of a Working Group to provide day-to-day support for schemes, particularly smaller and restricted schemes.
Please email us should you require further information on our key focus areas,