MediShield Life Scheme (Amendment) Bill

Order for Second Reading read.

3.40 pm

The Minister of State for Health (Ms Rahayu Mahzam) (for the Minister for Health): Mr Deputy Speaker, on behalf of the Minister for Health, I beg to move, "That the Bill be now read a Second time".

MediShield Life, our national health insurance scheme, was launched in 2015 and is an integral part of Singapore's "S+3Ms" healthcare financing framework, comprising subsidies, MediShield Life, MediSave and MediFund. MediShield Life protects all Singaporeans against large healthcare bills for life, regardless of pre-existing health conditions. This ensures that no Singaporean is denied appropriate healthcare due to an inability to pay.

The MediShield Life Scheme Act 2015, or the Act, was enacted in 2015 to support the establishment, governance and administration of MediShield Life. The Act has not been amended since it was passed. Since then, two key developments have taken place, which warrant amendments to the Act.

First, the landscape for healthcare delivery has evolved since MediShield Life's launch in 2015. The centre of gravity for healthcare delivery has been shifting to the outpatient, community and home settings, because not all patients require care in a hospital for their treatment. With this shift, more patients can benefit from easier access to necessary care.

To support this, MediShield Life coverage has been gradually expanded to more types of treatments beyond the acute inpatient setting. For example, in 2020, we expanded MediShield Life to cover inpatient palliative care within community hospitals and inpatient hospices. We are continuing our efforts to do more to support care outside of the acute inpatient setting, in the community and at home.

Last month, the Ministry of Health (MOH) announced that MediShield Life's coverage would be expanded to new outpatient treatments and home-based medical care. One example is the Home Ventilation and Respiratory Support Service (HVRSS), which provides mechanical-assisted ventilation to persons with breathing insufficiency, in the comfort of their homes. We need to amend the Act to allow MediShield Life to cover the increasing number of treatments that are now being delivered beyond the hospital setting as well as new care models that may emerge in the future.

Second, over the last nine years since its launch, the Government has gained more experience in administering MediShield Life. We have identified issues that have limited our ability to administer it effectively and efficiently. A key area to be covered in this regard is premium recovery.

When MediShield Life was made universal in 2015, it became mandatory for all Singapore Citizens and Permanent Residents to pay their premiums and contribute to the national risk pool. This also means that we must recover premiums from those who are able to but evade making payments.

Having had nine years of experience administering this, we have identified areas where the Act needs to be strengthened to better support premium recovery and improve scheme administration. In view of these developments, the MediShield Life Scheme (Amendment) Bill, or the Bill for short, seeks to amend the Act to achieve three objectives: (a) support expansion of coverage to new models of care; (b) strengthen provisions to support premium recovery efforts; and (c) improve scheme administration. Allow me to elaborate.

Our first objective is to support the expansion of MediShield Life coverage to new models of care received outside the physical premises of healthcare providers. This requires amendments in two areas.

First, we will amend the Act to redefine where treatments or services can be received. Today, section 3(1) of the Act requires the insured to receive treatment or services in an approved medical institution. However, going forward, clause 3 of the Bill amends section 3(1) to enable MediShield Life to cover medical treatment or services received by the insured, as long as it is from an approved medical institution. This means that the scheme will be able to cover care that is received entirely outside the premises of a medical institution and provides flexibility to cover newer care models that may develop in future.

Second, we will set out a clearer and more robust governance framework that allows scoped approvals, and suspensions and revocations of such approvals, of medical institutions in respect of approved medical treatment or services they provide under MediShield Life. This will allow MediShield Life to support patient access to new models of care whilst ensuring appropriate use of MediShield Life Fund monies.

Therefore, clause 4 of the Bill introduces the new sections 3A and 3B which set out the framework for scoped approvals, and suspensions and revocations of such approvals. Under the framework, the Minister for Health can approve providers to be approved medical institutions in respect of specific approved medical treatment or services and/or specific delivery modes for the purposes of MediShield Life.

Additionally, where a "medical institution" has been granted more than one licence under the Healthcare Services Act 2020 to provide "licensable healthcare services", the Minister has the prerogative to approve all, or only one or some of such licensable healthcare services provided by the approved medical institution for the purposes of MediShield Life. We will also introduce provisions to enable the Minister to impose conditions of approval and to suspend or revoke the approvals given.

To support the framework, clause 2(c) of the Bill amends section 2(1) by introducing a new concept of "claimable medical treatment or services". This ensures that the scheme only covers medical treatments or services provided by approved medical institutions according to the scope of their approval. Under the new amendments, the Minister is also empowered to grant approvals to medical institutions.

For example, while HVRSS will be an approved medical service from late 2025 onwards, it does not follow automatically that all providers will be able to make MediShield Life claims for it. MediShield Life will only cover HVRSS where a medical institution has been approved in respect of the service for the purposes of MediShield Life, and if the service is provided in accordance with the conditions of that medical institution's approval.

Taken together, the amendments will allow MediShield Life to be responsive to emerging models of care. It will also enable the Act to be more targeted in its approvals, and suspension and revocation of the approval of providers and their claimable medical treatment or services. This will strengthen the accountability of approved medical institutions and ensure compliance with the claim guidelines for MediShield Life.

Let me move on to the second objective: amending the Act to strengthen our premium recovery efforts. MediShield Life is a universal scheme which relies on collective responsibility through risk-pooling, to provide all Singapore Citizens and Permanent Residents peace of mind in affording large, unexpected healthcare bills throughout their lives. All policyholders must play their part by paying their premiums. This ensures that MediShield Life can continue to meet its obligations and support those of us who fall ill and need to make a claim.

At the same time, we recognise the need to keep premiums affordable, especially for vulnerable groups. This is why the Government provides strong support in the form of premium subsidies for lower- and middle-income households, Pioneer Generation and Merdeka Generation subsidies, and additional MediSave top-ups.

We also have a comprehensive set of measures to facilitate the payment of premiums. For example, for those who have missed premium payment due to insufficient MediSave balances, we remind them to top up MediSave and facilitate the process for immediate family members to take over premium payment. For those who need further help with their premiums even after subsidies and MediSave use, and have limited family support, we will assess their eligibility for Additional Premium Support (APS).

However, there are some individuals who do not pay their premiums despite these measures and become defaulters. In such cases, premium recovery and enforcement is needed. Any owed premiums that cannot be recovered will affect the MediShield Life Fund's sustainability and ultimately, affect MediShield Life's ability to meet its claims. If left unrecovered, these debts will have to be shouldered by other policyholders in the form of higher premiums.

A key enabler of this premium recovery process is the service of a demand note. Today, a demand note needs to be served before recovery measures, such as the appointment of an agent to recover outstanding premiums, and the imposition of interest and penalties for late payments can commence. The note may be served by the prescribed recovery bodies under the Act – the Central Provident Fund (CPF) Board and the Inland Revenue Authority of Singapore (IRAS). It notifies defaulters of their owed premiums and of the time by which these must be paid before further measures are taken.

We will amend the Act to recognise the different modes through which demand notes and other documents, are served on a defaulter. At present, demand notes are only deemed served if sent by registered post to a person's residential address provided in accordance with section 31 of the Act or any correspondence address provided by the person under certain prescribed circumstances. This is pursuant to regulations made under the limited scope provided by section 34(2)(k) of the Act.

However, this has impeded the recovery of outstanding premiums, such as in cases where no valid address information on the defaulter is available or service at an overseas address is required. Clause 10 of the Bill inserts the new sections 33A and 33B. The new sections provide how demand notes and other documents permitted or required by or under the Act to be served may be effectively served. With those new sections, section 34(2)(k) of the Act is no longer necessary and will be deleted by clause 11.

This would include serving them through additional modalities such as digital means, which will improve operational efficiency and streamline premium recovery actions for the recovery bodies. For example, a demand note may be served by sending it to an email address of a person where there is deemed consent to such service in accordance with the new section 33B(3)(b).

The Minister is also empowered to make regulations to allow a demand note to be served via an existing electronic service such as CPF Board's "my cpf" portal or IRAS' "myTax Portal" by applying the requirements set out in existing laws regarding these electronic services to the service of demand notes by CPF Board or IRAS respectively.

This facilitates recovery bodies in their recovery efforts, especially in relation to individuals on whom they were previously unable to serve demand notes and documents by registered post.

While we have a strong set of recovery measures to ensure the sustainability of the scheme, we should take a calibrated approach based on the means of defaulters. For example, some defaulters may come from lower-income households with complex circumstances. We should be more empathetic towards such groups of people and provide them a longer time to pay their outstanding premiums. On the other hand, premium recovery should proceed along the normal timelines for those with more means to pay their outstanding premiums, such as individuals from higher-income households.

To support this, clause 9 of the Bill amends section 28 to broaden the scope for access and use of means information to assess whether premium recovery and enforcement measures under Part 3 of the Act should be exercised on premium defaulters with lesser means.

Finally, let me touch on the last objective: amendments to improve the administration of the scheme, which aim to streamline, clarify and strengthen existing processes.

First, we will specify MediShield Life premiums in a manner that is more accessible, such as on MOH's website, instead of legislation. Currently, MediShield Life premiums must be prescribed in regulations. There is scope to enable premium amounts to be more conveniently accessed by Singaporeans as well as to streamline the administrative process by reflecting premium revisions for operational efficiency.

Therefore, going forward, clause 5 will amend section 4 to allow the amount of premiums payable for each insurance period to be specified in a prescribed manner, including a website, with consequential amendments made by clause 11 to section 34(2). This mirrors the practice adopted for CareShield Life, our national long-term care insurance scheme.

Second, we will make clear the date when a person is taken to attain a particular age for the purposes of calculating their MediShield Life premiums. This is achieved through the amendment to section 2(4) of the Act by clause 2(f).

For most Singaporeans, their age is taken to be on their birth anniversary. However, there is a small group of individuals whose birth date and/or month cannot be ascertained. Currently, our practice is to take their birth date to be on the first day of the month in which the individual was born, if their birth date cannot be ascertained; and their birth month to be in January, if their birth month cannot be ascertained. This is not currently set out in legislation. The proposed amendment to section 2(4) will clarify this.

There is another group of individuals who are born on a leap day. For them, MediShield Life starts on 29 February in the year they are born and in subsequent years, their birth anniversary is taken to be on 1 March. Going forward, the birth anniversary for these individuals will be taken to be on 1 March in non-leap years, and on 29 February in leap years. This mirrors the approach taken by CareShield Life today and ensures consistency across our schemes.

This amendment will not impact these individuals' MediShield Life cover or premiums, as there will not be any breaks in their coverage and premiums continue to be calculated based on their age over the insurance period.

Lastly, we will expand the scope of offences arising out of false or misleading information provided under the Act.

Today, section 19 makes it an offence where a person knowingly provides material information which is false or misleading and knowing that the information will be included in a health declaration, means declaration or claim application. However, such information may also impact the payment of benefits under MediShield Life, as well as the disbursement of premium subsidies or APS.

Therefore, the scope of such offences will be expanded to include cases where the information provided may affect the amount of grants, subsidies or benefits to be paid or given to an individual. The amendments by clause 6 to section 19 provide for this.

The amendments will enable us to take a stricter stance against such offenders and ensure the proper payment of claims as well as the disbursement of grants and subsidies, to protect the interest of Singaporeans.

Mr Deputy Speaker, let me conclude. The Act serves as the fundamental legislative framework that enables the implementation and operation of MediShield Life, an important component of our S+3Ms healthcare financing framework. This Bill ensures that coverage of MediShield Life keeps pace with changes to our healthcare landscape whilst allowing the Government to more effectively and efficiently administer the scheme. Mr Deputy Speaker, I beg to move.

Question proposed.

Mr Deputy Speaker: Ms Jessica Tan.

3.57 pm

Ms Jessica Tan Soon Neo (East Coast): Thank you, Mr Deputy Speaker. With an ageing population and people living longer, healthcare needs and costs are rising. The proposed expansion of MediShield Life coverage and benefits will manage healthcare costs especially for larger bills and make them more affordable for Singaporeans.

The higher claim limits for hospitalisation and inpatient care as well as existing outpatient treatments, the inclusion of new benefits to cover additional outpatient treatments including mental health, community and home-care treatments, and the extension of MediShield Life coverage to new, potentially life-saving therapies that are proven safe, clinically and cost effective such as Cell, Tissue and Gene Therapy Products, recognise and provide for the shifts in healthcare and patient needs especially for larger bills.

I do note that the Minister of State in her speech did share about the fact that these new treatments are only for approved medical institutions and only for the approved scope of these medical institutions. If this is the case, I think it will be also very important that this is clearly communicated to patients when they do seek these treatments, so that we will not have a situation of the assumption that it will be covered and then we have a situation where they are not covered, they are not eligible.

With increasing healthcare cost, these proposed changes are welcomed as it will help patients manage large medical bills. The increase in claims for existing outpatient treatments covered by MediShield Life and the inclusion of additional new patient treatments will hopefully encourage more appropriate and right-siting of care. Currently, some patients do opt for inpatient care at hospitals for treatments that may not require hospitalisation as claims or coverage for these treatments are not covered for outpatient treatments or day surgeries, leading to unnecessary costs and wastage.

When one is ill, being able to afford and have access to appropriate treatment is not only important for the well-being for persons who are ill but also gives peace of mind to the patient and their family members. Thus, having appropriate and sufficient healthcare insurance to handle unexpected or sudden health situations that require surgery or major treatments and hospitalisation will help ensure affordability for all, for treatments and for large bills.

So, while I support the proposed amendments, there are a few points I would like to speak on and seek clarification in my speech today and the focus is on how these amendments may impact the individual. I know that the Bill is meant to handle the specific frameworks for the implementation of MediShield Life, but ultimately, MediShield Life touches lives and touches individuals so I would like to touch on these points.

So, first, on higher deductibles and affordability; second, on more support and guidance on Integrated Shield Plans and decisions on Integrated Shield Plans; third, on pre and post-hospitalisation coverage; and fourth, premium subsidies and MediSave top-ups.

Let me now touch on higher deductibles and affordability. While the proposed amendment includes premium assistance provided to the lower- and middle-income individuals in older age groups, the recommendations do include an increase to inpatient deductibles and the introduction of a new outpatient deductible of $500. This may be financially challenging for some. The increase in MediSave withdrawal limits will help patients pay for the increase in deductibles. Deductibles are an important feature of MediShield Life to prevent overuse or overconsumption of healthcare spending and to ensure that coverage of MediShield Life is for specifically larger medical bills. Before patients can claim for MediShield Life payouts, they need to pay deductibles. So, while deductibles are an important feature to manage, as I said, the overuse and can be paid with MediSave, the proposed increase for inpatient deductibles and the introduction of a new outpatient deductible may place a financial strain for some, for example, for those who are unemployed and have no income or low balances in their MediSave. If faced with such circumstances, what help can they seek?

On pre- and post-hospitalisation coverage, in the consideration for expansion of coverage for MediShield Life to cover large medical bills, was consideration given to include pre and post-hospitalisation treatments prior to the need for inpatient services? Maybe I should have asked this question of the Review Committee rather than of the Minister of State. But the reason why I am asking for this is because usually, most patients, prior to admission will require several consultations and scans or tests to be done to ascertain their condition and early-stage treatments which are usually outpatient. After discharge from hospitals, they may also require recovery treatments, and these can add up and sometimes cost more than a hospital stay.

I understand that there is always trade-offs and balances of what gets covered and premium affordability. But given the intent of MediShield Life to ensure affordability for larger medical treatments, can there be an option in MediShield Life for those who require coverage for pre and post-hospitalisation treatment to pay an additional premium for the coverage. While there could be adverse selection and this will increase premium payable for those who do select the premium, it will be more affordable than having to make out-of-pocket payment for pre and post hospitalisation charges.

I know this is a very difficult decision because at the end of the day, it is about over-consumption as well as coverage, but I hope that some serious consideration can be given to that, especially now that more treatments are outpatient, moving towards outpatient treatments given the improvements in medical technology.

I have also received feedback from our residents – and it was also reported in Forum of The Straits Times in August this year – that getting appointments to see specialists at public hospitals may take time, sometimes as long as a few months. For some who have an Integrated Shield Plan (IP) that covers pre- and post-hospitalisation charges, the reason they have cited for having IPs to enable them to be able to get an earlier appointment to consult a specialist either at a public hospital or private hospital but usually they do it at the public hospital and the feedback is that as a non-subsidised patient, it is easier to get an earlier appointment to see a specialist at the public hospital and to have the appropriate tests and diagnosis.

So, apart from coverage of medical expenses, on the other side is the capacity of specialist consultation and tests at public hospitals and this will need to also be balanced and reviewed. I know this is again not part of the Bill, but at the end of the day, when you look at MediShield Life and you look at coverage, it is about treatment that is received and the institutions where they are received – and our public hospitals are held in very high regard for the quality of their services.

Let me talk about more support and guidance on IPs.

With the increase in the claim limits and expansion of coverage and benefits of MediShield Life, will MOH consider providing more support and advice to Singaporeans on the appropriate coverage for healthcare insurance? And why I am saying this is because it was reported that about half of patients with IPs for private hospitals still end up using subsidised care at public hospitals. So, what it means is that they are paying for healthcare insurance that they do not even use. This is costly and unnecessary expense and put financial strain especially for seniors as IP premiums cost a lot more. While there is a lot of information on IP including cost comparisons, the fact is that so many are paying for what they do not use and that shows that more can be done to help Singaporeans make the right decisions on their healthcare insurance.

For some, the proposed amendments with the increase in claim limits, expansion of coverage and benefits could mean that MediShield Life may indeed give adequate coverage and the decision could be to give up their IPs which cost more as one ages.

We do need however to understand that the decision for one to give up an IP needs to be considered carefully as eligibility to purchase coverage for IPs require one to be in good health and with no pre-existing conditions. So, if they give it up, they would problems getting back on. Those decisions are quite serious. But the cost of IP really is quite high as one ages.

Finally, on premium subsidies and MediSave top-ups. With the higher claim limits, expansion in coverage and increased benefits, premiums will increase and there will be a cap on the average about 22% on average with a cap of up to 35% over the three years. The proposed premium subsidies and MediSave top-ups are needed and will help the affordability of premiums and will cushion the impact of the increase for most Singaporeans.

For the Enhanced Mean-Tested Premium Subsidies for Singapore Citizens, I would like to ask MOH if they would review and consider eligibility for the lower- and middle-income individuals who live in properties with annual value (AV) greater than $25,000 but do not own the property they live in or any other property? This is not a bIanket approval that I am asking for but to be able to look at it on individuals that may need it and why I say this because we do have residents who cannot afford to own their own homes and they have on the goodwill of their relatives been able to stay with their relatives. And some of them live in residences that are valued higher than $25,000 and AV is what is used for means-testing and so some may require support for the premium but given their residential address, will not be eligible for the subsidies. So, I hope that MOH would look at this when appeals of such requests come up.

So, in conclusion, Mr Deputy Speaker, while it is important that healthcare remains affordable and there is adequate medical coverage, paradoxically, our goal should be to stay healthy and not to have to use it often. In the spirit of Healthier SG, we should all do our part and lead healthy lifestyles. This would not only lower healthcare costs which is what we are talking about today but also improve the quality of life for individuals. The proposed pilot to allow those over 40 years of age to redeem premium discounts with Healthpoints via the Health Promotion Board's (HPB's) Healthy 365 app is a refreshing approach and a good nudge to promoting a healthy lifestyle. So, I hope to see how this will work out as it goes, as it is implemented.

Mr Deputy Speaker, when the MediShield Life Scheme was first introduced in 2015 by then Health Minister, Deputy Prime Minister Gan Kim Yong, he reminded us that, I quote, "MediShield Life Scheme is the embodiment of Singaporeans' aspiration for a more inclusive, caring and progressive society". The proposed amendments are in line with the aspiration and principle to ensure that quality healthcare is accessible and affordable to all Singaporeans who need it. Mr Deputy Speaker, I support the Bill.

Mr Deputy Speaker: Mr Gerald Giam.

4.09 pm

Mr Gerald Giam Yean Song (Aljunied): Mr Deputy Speaker, the MediShield Life Scheme (Amendment) Bill 2024 introduces several changes to the MediShield Life framework to adjust premium structures, enhance administrative powers and improve affordability of healthcare coverage. I would like to seek some clarifications on several areas that may impact Singaporeans financially and administratively.

Clause 11 amends section 34 of the Act, which grants the Minister broad powers to make regulations, including determining premium rates for different classes of insured persons. MediShield Life premium subsidies now consider both per capita household income (PCHI) and the AV of one's residence. The AV tiers provide the highest subsidy to lower income insured persons living in properties with AVs of up to $21,000 and a reduced subsidy for AVs between $21,000 and $25,000, while AVs above $25,000 receive no subsidy, unless they are from the Pioneer or Merdeka Generation.

This criterion could present a financial challenge for some low or no-income households, particularly retirees living in private property and are born in 1960 or later. These individuals may face rising medical bills yet do not qualify for premium subsidies due to the property they live in. Many of these elderly Singaporeans are unlikely to downsize their homes, especially if they are currently suffering from serious illnesses. The physical and emotional disruption of relocating during a vulnerable period is impractical and could worsen their health conditions.

For retirees and other low-income households, I urge the Government to consider removing AV as a means-testing criterion. Minimally, those with AVs above $25,000 should still be allowed to apply for premium subsidies, and a holistic and transparent assessment should be made based on their individual circumstances. This approach would allow the scheme to target subsidies more effectively towards those who genuinely lack cash flow for their healthcare needs.

Clause 5 grants the Minister flexibility to set premium rates through prescribed means, possibly via online publications. Although this change could streamline the process, I have some concerns about the stability and predictability of premium rates. Policyholders, especially those with lower incomes, rely on consistent healthcare costs to plan their finances. Frequent premium adjustments could challenge their ability to budget effectively.

Will the Government establish a regular schedule for premium adjustments, and if not, how much advance notice will policyholders receive to prepare for changes? This will provide policyholders with more transparency and predictability regarding their healthcare expenses.

Clause 4 grants the Minister discretion to approve medical institutions and the treatments they offer as eligible for MediShield Life claims. Although this change may help manage costs, it could also limit access to necessary care if certain treatments or institutions do not receive approval. Unapproved services might force policyholders to pay out-of-pocket, discouraging them from seeking essential treatment.

Could the Minister of State clarify if the criteria for approving medical services, and a complete list of approved services and institutions will be published regularly? This will help policyholders to make informed healthcare choices and avoid unexpected costs.

Additionally, does this amendment allow the Minister to designate Traditional Chinese Medicine (TCM) and other traditional medical practices as approved medical treatments in the future? Many Singaporeans rely on TCM and other traditional practices for managing chronic conditions and maintaining overall health.

Clause 6 broadens the scope of offences related to false or misleading information in health declarations, means declarations or claims. This amendment aims to deter fraud, but it may disproportionately impact elderly or less tech-savvy policyholders who may make honest mistakes in their submissions.

What are the provisions for rectifying minor or first-time errors, especially for vulnerable groups? Establishing a grace period or correction mechanism would prevent harsh penalties for honest mistakes, particularly for seniors unfamiliar with digital processes.

Clause 9 allows the Government to use means information to assess eligibility and support recovery actions for outstanding premiums. Although this approach may ensure targeted resource allocation, it could place additional pressure on low-income policyholders. Aggressive recovery actions, if based primarily on financial data, could create financial stress for households already struggling to meet healthcare costs.

Will the Government provide safeguards like automatic premium loans or deferred payment options to protect financially vulnerable policyholders and help them maintain coverage without incurring penalties? Will these policyholders lose coverage if they still fail to pay their premiums?

Clause 10 introduces electronic methods for serving official documents, including email, which may improve efficiency. However, policyholders who are less comfortable with digital platforms might miss important updates, potentially leading to unintended coverage lapses or penalties.

Does the Government offer additional communication methods, such as phone calls or in-person notifications, to ensure all policyholders receive and understand crucial information?

Mr Deputy Speaker, this Bill seeks to enhance the MediShield Life framework, but these changes must not place unnecessary burdens on those who rely on the scheme the most. For low-income households, I urge MOH to review the use of AV as a criterion for means testing, so that retirees and those with limited cash flow can receive subsidies based on their actual financial need.

Sir, I support the Bill, but I look forward to the Minister of State's responses to my questions.

Mr Deputy Speaker: Ms Ng Ling Ling.

4.16 pm

Ms Ng Ling Ling (Ang Mo Kio): Mr Deputy Speaker, the challenges that confront healthcare in Singapore are two-fold: the ageing population and the rising costs of healthcare. The recommendations and inputs of the MediShield Life Council in its 2024 review are timely in ensuring co-insurance and deductibles in MediShield Life remain affordable for Singaporeans, while considering the shift in healthcare delivery from hospital care to outpatient and home-based care, as well as the advances in medical technologies.

I welcome the changes and support the latest MediShield Life Scheme (Amendment) Bill. Notwithstanding this, I would like to raise some clarifications relating to: one, the enhanced eligibility and coverage expansion for outpatient treatments and advanced therapeutics; two, deductible and co-insurance changes; three, premium adjustments; and four, emphasis on preventive care.

Firstly, I am glad to know that to support the rising costs of medical bills for Singaporeans, the Government will be increasing existing inpatient and day surgery claim limits on MediShield Life to fully cover nine in 10 subsidised bills. I welcome the increase in claim limits as it will ensure that Singaporeans can continue to receive adequate support during critical hospitalisation without compromising on the scheme's sustainability.

Additionally, the Bill has made amendments to include newly defined terms such as "approved medical institution", "claimable medical treatment or services" and "licensable healthcare service". By referring healthcare providers to those licensed under the Healthcare Services Act 2020, the new definitions broaden the range of providers, such as outpatient facilities, community care providers and potentially, even home-based medical care that will be eligible for MediShield Life coverage.

This allows patients to benefit from outpatient facilities as outpatient claim limits are also refreshed to fully cover nine in 10 subsidised bills. With the expansion of outpatient coverage, patients will also have more access to convenient care options beyond the traditional hospital settings.

Similarly, I am supportive of the expanded coverage of high-cost treatments and high-cost drugs for blood conditions and conditions with childhood onset, that are clinically effective and cost-effective. This will ensure that these medications remain accessible to those who need them, while keeping insurance premiums and overall bill costs affordable. Nevertheless, given the newly recommended claim limits mentioned for high-cost treatments, I would like to ask how would MOH address concerns about the sustainability of covering such treatments in the long run?

I have several clarifications to make regarding the expanded eligibility and the impact on service access. I would like to ask how are outpatient services selected to be included in MediShield Life coverage and what cost-effectiveness assessment has been done to assess these newly covered outpatient services?

I would also like to ask MOH what safeguards are in place to control cost increases resulting from a higher volume of outpatient claims to be expected? Additionally, how does MOH plan to balance the inclusion of a wide range of outpatient services while preventing over-utilisation, which may drive up overall healthcare costs in the long term?

Secondly, I understand that MOH intends to increase both the inpatient deductible by up to $1,500 and the outpatient deductible by up to $500 per year. My concerns lie with the impact of increased deductibles on lower-income households, especially lower-income seniors who are staying alone, as well as those with frequent outpatient needs. These families and individuals may not have sufficient MediSave to cover the deductibles and may end up having an increased out-of-pocket cashflow burden.

I hope that MOH can consider additional support or a tiered deductible structure for such cases through some forms of means-testing of their household incomes. This will help patients to worry less about their out-of-pocket payments if they have insufficient MediSave funds.

Additionally, I also hope that MOH can consider including Flexi-MediSave in the consideration of the deductibles that are currently calculated. Many residents of mine in Jalan Kayu, who have issues with their medical bills, spoke to me about the limits imposed on the Flexi-MediSave, increasing their out-of-pocket cash payments. These are especially so, for those who have frequent Specialist Outpatient Clinic appointments for regular reviews of their medical conditions.

Besides deductibles, I also understand that MOH will be introducing a tiered co-insurance structure ranging from 3% to 10% for outpatient treatments, which mirrors the current co-insurance component for the inpatient or day surgery care. I do support this move to ensure large outpatient bills remain affordable for subsidised patients. Nevertheless, I hope to understand how MOH will determine the tiered co-insurance. What will be the specific threshold that will dictate that co-insurance percentage to be used for the outpatient bill and how is this threshold calculated by MOH?

I would now like to focus on a key concern that impacts our residents the most – the adjustments of the MediShield Life premiums. With the rise in policy claim limits and the expanded scope of coverage to include high-cost treatments, premium adjustments are an inevitable measure to maintain the sustainability of MediShield Life.

However, this increase in premiums will particularly impact older Singaporeans, some of whom may not have accumulated sufficient MediSave funds over their working lifetime to cover these rising costs. While the Government has assured us that measures are in place to mitigate these changes, I would like to understand more about how MOH plans to better support our lower-income seniors, especially those who may have minimal MediSave balances in the long term.

I fully support the Government's allocation of an APS amounting to $80 million, as it will provide critical support to those who are unable to afford their premiums even after premium subsidies or those who lack family support. However, I am interested to know how effectively this support reaches those in need. May I ask, on average annually, how many individuals have applied and been approved for the APS to cover their MediShield Life premiums so far? Additionally, given that some seniors may face challenges in navigating the application process, can there be a proactive system to identify those who will have insufficient MediSave funds for auto-inclusion for the APS?

I believe this would be especially helpful for seniors whose MediSave balances may become depleted over time due to frequent hospitalisations and those who lack family support. Ensuring accessibility to this support without additional administrative application burdens on the applicants' part, would help safeguard our seniors from the risk of being uninsured due to financial constraints or the lack of literacy to navigate application process.

Finally, I would like to touch on incentivising preventive care using MediShield Life. On various occasions, many of my colleagues in this House, have shared their views on how we can incentivise residents to take up preventive care measures by offering incentives or premium discounts. I am glad that the Government has accepted the Council's recommendation to pilot offering premium discounts to those who lead healthier lifestyle, such as through Healthpoints in the HPB's Healthy 365 programme.

I believe that financial incentives would be useful in empowering individuals to act according to their preference for a healthier lifestyle. This approach not only encourages preventive action, but may also, over time, reduce the burden of claims on MediShield Life, ultimately helping to contain premium burden for everyone.

In this regard, I hope MOH can consider broadening the range of preventive actions that qualify for incentives, beyond physical activities alone. For example, regular health screenings, vaccinations and active management of chronic conditions could also be rewarded, as they play a crucial role in detecting and addressing health issues early. Additionally, could MOH consider offering a tiered discount system, where individuals, who consistently participate in preventive care initiatives or over multiple years might earn progressively larger discounts on their premiums? Such measures would further encourage longer-term commitment to healthier living.

Furthermore, I would like to suggest an outcome-based subsidy model for those with chronic conditions. Under this model, individuals could receive additional subsidies if they demonstrate improved health outcomes over time, such as better control of blood pressure or blood sugar levels. This would serve as an incentive for individuals to actively manage their conditions and could, in the long run, lead to reduced claims on MediShield Life by decreasing complications related to chronic diseases.

Mr Deputy Speaker, the MediShield Life Scheme has been an important policy tool to support Singaporeans in managing large hospitalisation bills and ensuring that essential healthcare services remain affordable to all. Today, as we are faced with the dual pressures of an ageing population and rising medical costs, the latest adjustments on policy claim limits and expansion of claimable items towards advanced therapeutics, as well as outpatient and home-based care, signal the Government's commitment towards supporting Singaporeans to care for their health and well-being.

As we continue to navigate those challenges, I believe that the healthcare needs of vulnerable groups, including our seniors and lower-income households, must be prioritised. These groups would likely feel the impact of rising premiums most over the longer term, especially if they do not have enough MediSave funds. Therefore, I hope that the Government can ensure that resources for these groups remain accessible and sufficient. I also hope that the Government can use this as an opportunity to consider how incentives in MediShield Life premiums and claims can better support preventive measures, as we work towards more sustainable healthcare for future generations.

Notwithstanding my considerations raised, Mr Deputy Speaker, I support the MediShield Life Scheme (Amendment) Bill.

Mr Deputy Speaker: Mr Neil Parekh Nimil Rajnikant.

4.27 pm

Mr Neil Parekh Nimil Rajnikant (Nominated Member): Mr Deputy Speaker, Sir, thank you for allowing me to join this debate on amendments to an important piece of legislation which aims to assist Singaporeans with their healthcare expenses. It is especially relevant now, with a growing ageing population.

The amendments before the House align the MediShield Life Scheme with the evolving healthcare needs. By enabling better oversight through approvals and conditions for medical institutions, the Bill promotes service quality and cost-effective healthcare delivery. These updates enhance Singapore's ability to deliver sustainable healthcare coverage, while managing public health funds efficiently. Medical institutions must now seek approval from the Minister to provide specific medical treatments eligible under the MediShield Life Scheme.

The Minister can impose conditions on service delivery modes like telemedicine, the provision of outpatient medical services remotely and at permanent premises to ensure appropriate healthcare delivery. The ability to revoke or suspend approvals ensures compliance with the Healthcare Services Act 2020, promoting accountability and service quality.

The Bill also ensures only treatments provided by approved institutions under specified conditions will qualify for MediShield Life claims, ensuring proper allocation of insurance funds. Amendments to clause 5 will allow for premiums to be published online for transparency, with rates varying by insured persons' risk profiles and needs. Also, clause 6 will expand scope of offences for false information to ensure accountability in health declarations and protect MediShield Life from abuse.

In my view, some of these changes, while introducing new compliance requirements, will benefit medical institutions from more streamlined approval processes and clearer service delivery standards, and will lead to improve patient care. During this transition, in order to avoid any disruption in claims processing, close coordination between insurers and health providers will be required.

Sir, I now have some specific clarifications for the Minister of State. First, what are the specific timelines for approval or rejection of applications by medical institutions for treatment coverage under MediShield Life? Second, will insured persons undergoing treatments, under the previous framework, continue to receive coverage during the transition period? Third, will the conditions for service delivery vary across institutions and how will these be communicated to the public? Fourth, what processes will be in place for institutions or individuals to appeal decisions related to approval revocations or for denial of claims?

Mr Deputy Speaker, Sir, notwithstanding my clarifications, this Bill has my complete support.

Mr Deputy Speaker: Dr Wan Rizal.

4.30 pm

Dr Wan Rizal (Jalan Besar): Mr Deputy Speaker, I rise in support of the Bill. MediShield Life has become an indispensable pillar of Singapore's healthcare system, providing critical coverage that ensures no Singaporean is left without access to essential medical treatment. This amendment Bill seeks to modernise and expand MediShield Life to meet the evolving healthcare needs. I commend the Ministry for its proactive efforts, especially, given today's complex and dynamic healthcare landscape.

Today, I would like to focus on just one critical issue raised by these amendments: the impact on financial sustainability of MediShield Life.

Sir, the amendments in this Bill allow for more flexibility in approving institutions and services for MediShield Life coverage. This flexibility can increase access to necessary treatments and provide coverage for services that better meet patients' changing healthcare needs. However, with this expansion comes the responsibility to carefully manage costs, ensuring that the scheme remains sustainable and the premiums remain affordable for all insured persons.

In recent years, we have seen significant growth in the scope of medical services in Singapore. This includes expanding telemedicine and digital health services, which offer accessible options like remote consultations and monitoring. Advanced treatments in areas like oncology and personalised medicine are also available, but often come at a high cost. Additionally, the importance of mental health has become increasingly apparent and pertinent, and there is a growing need for affordable mental health services within our healthcare framework.

While the current amendments allow for the inclusion of more institutions and services, I ask the Ministry to consider mental health services within MediShield Life in future evaluations, especially as demands for these services grow.

As the demands for these varied and sometimes high-cost services grow, we must consider how MediShield Life can responsibly support new healthcare needs, including mental health, while maintaining the scheme's financial sustainability. For instance, including private hospitals offering specialised treatments, such as advanced cancer therapies, could lead to high demand and increased claims under MediShield Life. Without careful oversight, a surge in claims could increase premiums for all insured members, affecting affordability.

To address these challenges and safeguard MediShield Life's financial sustainability, I urge the Ministry to consider three key measures.

Firstly, to establish clear criteria for essential coverage, defining essential versus optional coverage within MediShield Life will help manage costs. By prioritising treatments that benefit the majority, we can ensure that resources are used effectively, preserving MediShield Life's affordability and accessibility.

Secondly, implement regular financial reviews. Regular reviews of MediShield Life's financial performance, especially concerning new services and approved institutions, would enable us to make timely adjustments. These reviews could act as an early warning system, identifying areas where costs may rise unsustainably and allowing for targeted measures to keep premiums stable.

Thirdly, is to explore sustainable mental health coverage. As the demand for mental health grows, I encourage the Ministry to consider ways to sustainably include essential mental health treatments in MediShield Life's coverage. Addressing mental health needs is critical to holistic care. By exploring financial sustainability options, we can ensure MediShield Life continues to evolve with our society's needs.

Expanding coverage thoughtfully and sustainably will allow MediShield Life to remain a robust healthcare safety net that provides affordable, reliable and essential care to all Singaporeans. Mr Deputy Speaker, in Malay, please.

(In Malay): [Please refer to Vernacular Speech.] Sir, this MediShield Life (Amendment) Bill aims to expand MediShield Life coverage to meet the ever-increasing healthcare needs of Singaporeans. With this revision, MediShield Life will be able to approve medical institutions and services that are eligible for coverage under this scheme.

However, in our effort to expand this coverage, it is crucial for us to ensure the financial sustainability of the MediShield Life scheme, so that premiums remain affordable for all citizens.

I have proposed three key steps to achieve this goal: firstly, establishing clear criteria for essential services; secondly, implementing regular financial reviews; and thirdly, considering sustainable ways to include mental health services in MediShield Life.

With these measures, MediShield Life will continue to be an affordable, reliable and relevant healthcare safety net for all Singaporeans.

(In English): Mr Deputy Speaker, in conclusion, I support the Ministry's efforts to keep MediShield Life responsive to Singaporeans' healthcare needs. However, we must ensure that these amendments are implemented with financial prudence. By establishing clear coverage criteria, conducting regular financial reviews and exploring sustainable ways to include essential mental health services, we can safeguard MediShield Life's long-term viability. Notwithstanding the concerns I raised earlier, I truly believe MediShield Life can continue to be a source of peace of mind for every Singaporean, supporting a healthier, more resilient society.

Mr Deputy Speaker: Dr Syed Harun.

4.36 pm

Dr Syed Harun Alhabsyi (Nominated Member): Thank you, Mr Deputy Speaker. In the context of my comments on this Bill, I declare that I am a medical practitioner in private practice. Since 2015, MediShield Life as a national health insurance scheme has afforded all Singaporeans universal and lifelong basic protection against large healthcare bills. And very importantly, this is regardless of age or pre-existing conditions. It is a key pillar to enable access to good healthcare, along with the other tenets of the "S+3M" strategy outlined by the Minister of State earlier, the rest being subsidies, MediSave and MediFund.

I note from the MediShield Life 2024 Review Council report that the principles anchoring MediShield Life continue to be: one, coverage for all, for life; second, protection against large medical bills, of course sized at the level of and for public healthcare; third, collective responsibility through risk-pooling at a national level; and fourth, affordable premiums with additional support for target groups and a clear commitment that no one will lose MediShield Life coverage because of an inability to pay premiums.

I also note that the Government has accepted the MediShield Life Council's recommendations for the MediShield Life 2024 Review and intend for the changes to be implemented progressively from April 2025 onwards.

Mr Deputy Speaker, to ensure long-term viability of such a national healthcare insurance scheme, healthcare providers need to operate within a framework of effective regulations, legislation and accountability mechanisms, much of which this Bill already attempts to address. Among other things, these would have to include ensuring quality of standards and to the extent possible, clinical guidelines to standardise care, regulations to ensure cost-effectiveness of treatment, transparency in billing and claims by the providers and accountability mechanisms, especially at the level of the providers.

These come with a view to keep the MediShield Life claims within what is fair, what is reasonable and what is clinically appropriate, and so that claims are neither allowed to be excessive nor exorbitant for any particular condition. The eventual intent, of course, is to ensure that at the national level, the MediShield Life premium remains affordable to sustain for every Singaporean.

I note that substantive portions of the amendment Bill look at two key areas: the first being approval, revocation or suspensions of medical institutions in respect of approved medical treatment or services under the new sections 3A and 3B; as well as amendments to Part 4 of the Act under Offences, specifically under False or Incorrect Health Declaration, Means Declaration or Claim Application.

My view is that the amendments proposed are sound and reasonable. It covers the breadth of licensable healthcare services and service delivery modes under the Healthcare Services Act in 2020 and lends further clarity to offences that could fall within the remit of MediShield Life claims.

However, as we increasingly consider the shifting of care from inpatient settings to outpatient, to home and to community settings and part of these are already articulated in the MediShield Life Council 2024 report, one can reasonably anticipate an even broader-based participation from private sector medical practitioners, not just those anchored in private hospitals but also potentially those working in home-based, in primary care and in community settings. This is especially with the MediShield Life Council report recommending expanding coverage to include new outpatient treatments and home-based medical care, such as repetitive transcranial magnetic stimulation, home ventilation and respiratory support services and outpatient parenteral antibiotic therapy.

With the changes not only to MediShield Life but also with the ongoing implementation by MOH for Healthier SG initiatives, the upcoming Health Information Bill slated next year and recent announcements by the Ministry relating to information sharing across public and private sector institutions on the National Electronic Health Records, I urge the Ministry to engage private sector medical practitioners more closely on the last-mile impact and concerns arising from the impending broad shifts to the healthcare landscape. Specifically, those coming from smaller or singular clinic entities and how they could be better supported in navigating these slew of changes that are ongoing and anticipated in the coming years.

I understand that perception surveys and stakeholder engagements are done from time to time to gauge the readiness of private healthcare providers on the potential changes that could be afoot in the healthcare sector. However, I am also concerned about the cumulative impact of regulatory and legislative changes being done in relative quick succession and how they are affecting private medical practitioners of smaller and singular clinic entities disproportionately.

It is notable that the number of private sector medical practitioners are not insignificant and based on the Singapore Medical Council's 2023 Annual Report, they make up about a third of all registered medical practitioners in Singapore, as of December 2023.

The structure and relationship of private hospitals vis-a-vis the private medical practitioners, are more heterogeneous and not as singular and strongly rooted as those in the public hospitals and that could add further complexity to ground implementation of MediShield Life claims.

For MediShield Life to be truly accessible and impactful to every Singaporean, as hoped and as intended by policy, a key enabler would be the medical practitioners themselves, who need to be supported well at the last mile in order to offer good custodianship of this scheme. I hope the Ministry will lend emphasis and greater support for this group as the proposed changes to the MediShield Life take root in the coming year.

This also runs in parallel to the point made for patients at the last mile by the hon Member Ms Jessica Tan about considering MediShield Life changes in wider context and not in isolation. Mr Deputy Speaker, my comments notwithstanding, I rise in support of the Bill.

Mr Deputy Speaker: Mr Yip Hon Weng.

4.43 pm

Mr Yip Hon Weng (Yio Chu Kang): Mr Deputy Speaker, Sir, this Bill promises important refinements to our MediShield Life scheme. Nevertheless, I seek clarifications on four key areas to ensure fair healthcare access for all Singaporeans, especially the elderly and those with limited mobility.

First, Mr Deputy Speaker, Sir, I am concerned about the potential impact of moving towards online publication on our less digitally savvy seniors. The Bill proposes that premium rates be specified in a prescribed manner, which may include a website. While I understand the intention to leverage digital platforms, many seniors still struggle with digital literacy. This shift could create a significant barrier to assessing vital information about their healthcare costs.

How will elderly residents who may not feel comfortable navigating online resources, access and understand their premium rates? What safeguards will be implemented to ensure they receive adequate notice of any premium changes?

Unexpected increases without sufficient warning could place an undue financial burden on vulnerable individuals. Should we not mandate both online and offline channels for premium information to ensure accessibility, transparency and fairness for all Singaporeans, regardless of their digital skills?

[Mr Speaker in the Chair]

In our digital-first, but not digital-only society, we must ensure our elderly residents are not left behind in understanding their healthcare costs. One suggestion is to conduct community outreach programmes for seniors to help them understand premium changes.

Secondly, Mr Speaker, Sir, the Telehealth Approval Framework can be clearer in some sections. This could impact telehealth access, particularly with the new provisions in section 3A regarding "service delivery mode".

This Bill appears to grant broad powers to approve or restrict specific delivery modes without a clear criterion. Why is this the case? Granting extensive powers without clear guidelines can lead to ambiguity and unpredictability. How will residents know which telehealth services are claimable under MediShield Life? A clear and readily available list of approved services is essential for both patients and providers. Furthermore, what will happen to existing telehealth claims when a provider's delivery mode approvals are modified? Will there be a grace period or transitional arrangements to avoid disrupting ongoing care? Clarity on this point is important to maintain patient trust and ensuring continuity of care. Regularly updating and clearly communicating telehealth claim approvals to the public can improve accessibility and transparency.

Additionally, should we not include statutory consultation requirements before restricting service delivery modes? Such consultations would ensure that decisions are well-informed and consider the needs of all stakeholders while protecting patients from unintended consequences. Despite the risks, telehealth holds immense potential for improving healthcare access, especially for those with mobility limitations. We must ensure this potential is not hampered by unnecessary restrictions.

Third, Mr Speaker, Sir, the proposed expansion of means-testing powers under section 28(1A) may spark anxiety among constituents. While I recognise the importance of responsible resource allocation, this expansion requires careful consideration to prevent vulnerable individuals from falling through the cracks. Simply expanding these powers without simultaneously strengthening the appeals process and establishing clear safeguards can be problematic.

The amendments raise several critical questions. How will these expanded powers impact residents who are asset-rich but cash-poor, a situation particularly prevalent among our elderly population? Many seniors own their homes, bought during their working lives, giving the appearance of wealth, yet may struggle to meet daily expenses. Will this Bill inadvertently penalise them for having illiquid assets? What concrete safeguards are being put in place to prevent the over-zealous application of these new powers?

Without clear guidelines and robust oversight, there is a real risk of denying subsidies to deserving individuals based on overly strict interpretations of their financial situations.

The Bill also lacks clarity on how means-testing information will be used. We need transparent criteria to ensure fairness. Means-testing should serve as a safety net, ensuring that those genuinely in need receive the support they require. It should not become a barrier to accessing vital healthcare services.

Fourthly, Mr Speaker, Sir, there are worries that the new framework for approving medical institutions outlined in section 3A might impact residents' ability to access their chosen healthcare providers. How will this transition impact residents currently receiving treatments at institutions that may not receive approval under the new framework? Will they be forced to switch providers mid-treatment, potentially compromising their health and well-being?

How will the Ministry ensure equitable access to care across all regions? Is there recourse for residents if their preferred local medical institution loses approval? What mechanisms will be in place to ensure that residents' voices are heard and their concerns addressed if their preferred provider is no longer approved?

Moreover, there should be a minimum notice period before approval changes take effect. This will allow patients sufficient time to make alternative arrangements and avoid disruptions to their treatment. For many patients, especially seniors, the relationship with their healthcare provider is critical in managing their health. This bond of trust and familiar routine provides comfort and encourages adherence to treatment plans, particularly for those with complex or chronic conditions. Disrupting this vital connection by forcing a change of providers can be unsettling and may even lead to patients abandoning necessary care.

Therefore, adequate time to adapt is crucial. A sufficient notice period before any approval changes is essential to allow patients, especially elderly residents, to adjust to new arrangements and maintain continuity of care without undue stress and disruption. A medical institution's approval process should not dictate a resident's access to essential and affordable healthcare.

In conclusion, Mr Speaker, Sir, we must carefully consider the implications of the MediShield Life Scheme (Amendment) Bill to ensure that it serves all Singaporeans equitably. We have discussed the importance of premium transparency, emphasising the need for accessible information for our elderly residents, both online and offline. I highlighted the necessity for a clear Telehealth Approval Framework that supports accessibility while avoiding unnecessary restrictions. I raised concerns about the expansion of means-testing powers, stressing the need for robust safeguards to protect vulnerable individuals, especially those who may appear asset-rich but struggle financially. Lastly, we examined the new medical institution approval framework and its potential impact on patient-provider relationships, underscoring the importance of maintaining continuity of care.

As we move forward, let us commit to creating a healthcare system that truly prioritises the needs of our residents, particularly our seniors and those with mobility challenges. It is our duty to ensure that no one is left behind in accessing essential healthcare services. Together, we can build a healthcare system that is not only robust and efficient, but also compassionate and inclusive. I support the Bill.

Mr Speaker: Minister of State Rahayu Mahzam.

4.51 pm

Ms Rahayu Mahzam: Mr Speaker, I thank the Members for their questions and comments on the MediShield Life Scheme (Amendment) Bill. Members have also raised questions on the changes to MediShield Life that were announced last month as part of the 2024 review. Let me briefly address these questions before moving on to comments relating to the Bill.

As the Members have pointed out, this review of MediShield Life is a significant one. The Government has accepted the recommendations made by the MediShield Life Council and we will be making three changes to the scheme.

First, we will ensure MediShield Life coverage remains adequate for Singaporeans, given the rise in healthcare costs. We are most concerned about major health episodes that result in large medical bills and cause financial strain. Therefore, MediShield Life's claim limits will be increased to better protect Singaporeans against such bills.

Second, healthcare is increasingly delivered outside of the hospital, in the community and home settings. This is more convenient for patients and their family members. To support this shift, we will enhance outpatient coverage significantly to include treatments, such as for depression.

Third, technological advancements have enabled the emergence of novel drugs such as cell, tissue and gene therapy products. While these have the potential to cure serious diseases, many of them are very expensive. Insurance, like MediShield Life, is a suitable way to finance such treatments, which are costly but have a low incidence rate. Therefore, MediShield Life's coverage will be extended to selected high-cost treatments that are clinically- and cost-effective.

With the enhancements in coverage, it is inevitable that premiums have to go up. However, the Government is committed to helping Singaporeans manage the premium increase and will provide an additional $4.1 billion in support measures, comprising MediSave top-ups and premium subsidies, for the next three years. This will more than offset the total increase in premiums of $1.8 billion over the same period. For more than nine in 10 Singaporeans, the additional support will more than offset the premium increase over the next three years.

Members have raised comments in three broad areas: one, affordability of healthcare for patients; two, affordability of premiums for policyholders; and three, sustainability of the scheme.

Let me deal with each of these in turn.

First, on affordability of healthcare for patients. Ms Ng Ling Ling, Ms Jessica Tan and Dr Wan Rizal asked how the MediShield Life Council had selected the new areas that MediShield Life coverage would be extended to in this review and whether other areas such as pre- and post-hospitalisation treatments or mental health services were considered for coverage in the review.

In general, the Council prioritised treatments that had significant affordability gaps, were suitable for risk-pooling, clinically- and cost-effective and supported the shifting of care to lower-cost settings. This includes expansion of coverage to repetitive transcranial magnetic stimulation, which is used to treat depression. We will also be raising the MediShield Life psychiatric ward limits by about 40%, from $160 per day to $230 per day.

In making recommendations on where to enhance or extend coverage, the Council strikes a fine balance between improving patient affordability and premium impact. That is not to say that patients do not have support for their pre- and post-hospitalisation needs, such as consultations or scans, when seeking subsidised care at our public healthcare institutions. Patients can already access a combination of subsidies and MediSave, where applicable, for these. Likewise for other mental health services.

Ms Ng Ling Ling and Ms Jessica Tan also asked about the impact of the deductible changes on patients, especially the lower income. The inpatient deductible has not been adjusted since the introduction of MediShield Life in 2015. With rising medical bills, the deductible has become less effective in sieving out smaller, more affordable bills that can be paid for by MediSave. The revision in deductibles will refocus MediShield Life's coverage on larger medical bills which, in turn, will moderate the premium impact. With significant enhancements to outpatient coverage and home-based medical care, we will also introduce a new outpatient deductible of $500. This will keep the scheme focused on larger outpatient bills and ensure premiums remain sustainable.

The Government will raise MediSave withdrawal limits in tandem with the MediShield Life changes to help patients pay for the higher deductibles.

I understand the Members' concern about the lower-income households and seniors who may not have sufficient MediSave. The MediSave top-ups by the Government will provide some help for these more vulnerable groups. I also wish to assure the House that Singaporeans who face difficulty affording their bills after subsidies, MediSave and MediShield Life, can apply for financial assistance such as MediFund. No one will be denied access to appropriate healthcare due to an inability to pay.

Second, on premium affordability. Ms Ng Ling Ling asked how vulnerable groups, such as the lower-income, elderly and those with chronic conditions, will be supported in affording their premiums. I wish to assure the Members that we have taken special care to support them. As announced by the Government earlier, premium increases will be capped at 35%, which mostly benefits older age groups. Premium increases will also be phased in evenly over the next three years to help all policyholders.

On top of this, older Singaporeans in lower- to middle-income households will also benefit from the means-tested premium subsidy enhancements that were recently announced. They will receive higher means-tested premium subsidies of up to 60%, from up to 50% today.

Seniors, including those with lower MediSave balances, will also benefit from additional MediSave top-ups provided by the Government, which can be used to pay their MediShield Life premiums. These include an increase in MediSave top-up for the Pioneer Generation by up to $300, bringing their maximum annual top-up to $1,200; an enhancement of the one-time MediSave Bonus under the Majulah Package for Young Seniors by $500; and an additional MediSave Bonus of $500 for Young Seniors and the Merdeka Generation with lower MediSave balances. Lower-income Singaporeans who require more support paying for the premiums after subsidies and top-ups may also be invited to apply for APS, which will fully cover their premiums for the next two years.

With this package of support, most seniors, regardless of income, will have their premium increases fully offset over the next three years. In addition, the MediShield Life premiums of older Pioneer Generation seniors will continue to be fully covered.

Mr Yip Hon Weng, Ms Jessica Tan and Mr Gerald Giam also asked how lower-income individuals who are living in or owning properties with high AV will be supported. It is true that such individuals receive lower means-tested premium subsidies on account of their higher AV properties. This is because those who live in properties with a higher AV would generally be better off than those who live in properties with a lower AV. While this approach is not perfect, it strikes a balance between being more precise in assessing applicants' means, while keeping the process simpler for most applicants.

However, the Government periodically reviews the eligibility criteria for subsidies so that Singaporeans with greater needs can continue to receive the support they require. For instance, the AV thresholds were recently raised earlier this year. With this, those staying in or owning these lower-value private properties can still qualify for premium subsidies.

Those who need more help or are facing extenuating circumstances may appeal for more assistance, which would be assessed on a case-by-case basis. Let me assure Members that no one will lose MediShield Life coverage due to an inability to pay premiums.

Lastly, sustainability of the scheme. Ms Ng Ling Ling and Dr Wan Rizal have commented about rising healthcare costs and the impact to the long-term sustainability of the MediShield Life scheme, especially with the expansions of MediShield Life coverage. This is indeed an area that the Government is committed to addressing. We have implemented various strategies on this front.

First, we have been re-designing the healthcare system to better support right-siting of care from our acute hospitals to other settings such as the outpatient, community and home settings where one can receive the same care at lower costs. Our enhancements to MediShield Life coverage through the recent review will also support patients in accessing care at such settings.

Second, we have been applying Health Technology Assessments to more high-cost technologies and drugs. This allows us to rigorously assess that a new treatment is clinically- and cost-effective before we extend financing coverage to it. This also allows the Government to negotiate for more competitive prices from industry, moderating the cost impact to our system.

Third, and most important, is our increased focus on staying healthy. This is why we have Healthier SG, which is our national initiative focusing on preventive health and chronic disease management. We have introduced premium discounts in this review, to complement our national efforts to incentivise healthier living, where Healthpoints can be redeemed for MediShield Life premium discounts.

I am glad that Ms Ng Ling Ling is supportive of this idea, and has raised useful suggestions such as broadening the range of activities that qualify for incentives and implementing a system to encourage sustained activity. We will take all of these into account as we study the outcomes of this pilot, before deciding whether to make the scheme permanent.

I thank the Members for their support of the MediShield Life changes. These will go some way in providing relief for Singaporeans amidst rising healthcare costs. Premiums will need to go up, but we have provided a significant package of support that offsets premium increases for more than nine in 10 Singaporeans over the next three years.

The Government will continue to work with the MediShield Life Council to review the scheme regularly to ensure that it remains a source of assurance for large healthcare bills and that its premiums remain affordable for Singaporeans. At the same time, we will continue to press on with our efforts to keep our healthcare system sustainable for many years to come.

I will now move on to address Members' questions and comments on the MediShield Life Scheme (Amendment) Bill. Let me address them according to the three areas of amendments we are making to the Act.

First, on supporting the expansion of coverage to models of care received outside the physical premises of providers. As mentioned earlier, we will enhance MediShield Life to cover more types of care, such as home-based medical or telehealth services delivered outside of the traditional hospital setting. This will allow more patients to receive the care that they need in a more convenient way.

Going forward, we expect to see the emergence of more care models where treatment or services are completely delivered outside of a physical medical institution. These care models may eventually become the standard of care. The MediShield Life Council will review the coverage of MediShield Life from time to time and recommend to the Government if it would be appropriate for the scheme to cover treatments and services offered under these models.

This Bill will provide flexibility for MediShield Life to cover such treatments and services in future, where we so decide to, which will allow patients to make claims for these treatments and services.

To Mr Yip Hon Weng's query on how patients can know which services are claimable under MediShield Life, I would like to share that new approved medical treatment or services, including home care and telehealth services, will be publicised through the MediShield Life Council's report, on the MediShield Life website and be stated clearly in the MediShield Life Scheme Regulations 2015.

In addition, the expansion of the scheme's coverage will be complemented by amendments setting out the framework for approvals and suspensions and revocations of approvals, of medical institutions under the scheme.

Mr Gerald Giam spoke about the criteria for approval of medical institutions. This framework will allow MOH to continue safeguarding and ensuring the appropriate use of MediShield Life monies, while maintaining a clear and robust framework for managing medical institutions participating under the scheme.

For instance, to be approved, the medical institution will need to have a valid licence issued under the Healthcare Services Act 2020. The scope of the medical institution's approval under the scheme is also tied to the specific licensable healthcare services that it is authorised to provide by its licence, as well as their respective service delivery modes.

The key appointment holders of the medical institution, as well as any medical practitioner that is employed or engaged to provide the approved medical treatment or services in that medical institution must also not be found to be in breach of certain requirements, such as being convicted of an offence involving fraud or dishonesty.

The Minister for Health may also impose conditions of approval, which could include requiring the medical institution to ensure that MediShield Life claims are submitted in accordance with the relevant claim rules.

Mr Yip Hon Weng raised concerns about the broad powers for approvals, suspensions and revocations, and how they will affect patients currently receiving treatment and services. Similarly, Mr Neil Parekh asked how the conditions of approval would apply and be communicated, whether there would be continuity of coverage for insured persons under the new framework, as well as the processes in place for the approval or rejection of applications, or for appeals related to revocations. Let me touch on all of these issues together.

First, as stated in my opening speech, the Minister is empowered to grant approvals to medical institutions under the new amendments. Unless there are extenuating circumstances, medical institutions that have existing approvals as of the date immediately before the amendments come into effect, can be approved in respect of approved medical treatment or services that are or are part of their existing licensable healthcare services and respective service delivery modes. Hence, to address Mr Yip Hon Weng and Mr Neil Parekh's concerns about continuity of care, we do not expect the care of existing patients to be disrupted by this transition.

Second, enforcement measures can now also be tailored to respond to specific medical institutions, or specific treatments or services offered by them that fail to comply with the requirements or their conditions of approval under the MediShield Life Act. With this, when we take action against the medical institution for other treatment or services which are not provided in compliance with the Act, we can still safeguard the patient's ability to continue making claims for approved medical treatments or services that are provided in compliance with the Act.

Let me illustrate how this works. A single medical institution today may be delivering multiple care models or treatment through different licensed healthcare services or different service delivery modes. Today, enforcement measures taken against an approved medical institution in a non-compliant area would involve suspending or revoking the approval of the entire medical institution.

The amendments, however, will allow the Minister for Health to suspend or revoke the approval given in respect of a specific medical treatment or service provided by a medical institution. This could be when a non-compliant service delivery mode is used by the medical institution. The approval for the medical institution to submit claims for other treatments or services via other delivery modes remain valid, and patients can still be covered by MediShield Life.

Mr Yip Hon Weng asked if there would be transitional arrangements in situations where approvals to medical institutions are suspended or revoked, to avoid disruptions to ongoing care of patients. The amendments require medical institutions providing any non-compliant medical treatment or services to inform all patients of the suspension or revocation of approval of such medical treatment or services immediately. Claims made by patients for such treatment or services provided before the suspension or revocation will continue to be processed without issue.

The Minister for Health can also permit claims for such treatment or services provided during the suspension or after the revocation, if necessary, to safeguard the patient's interest. This power to safeguard MediShield Life monies will be exercised judiciously, to minimise any undue care disruptions to patients.

Third, let me assure Members of the House that there are safeguards in place to ensure accountability and due process.

To Mr Neil Parekh's question, the conditions of approval will be made clear to medical institutions and we have provided clear grounds for when approvals may be suspended or revoked under the Act. These include circumstances where the approval has been obtained fraudulently or if the licence granted to the medical institution under the Healthcare Services Act 2020 to provide the licensable healthcare service that the approved medical treatment or services is or is a part of has also been revoked or suspended.

For these reasons, we do not think it is ideal to include statutory consultation requirements before restricting service delivery modes, as Mr Yip Hon Weng has suggested. In cases where patient safety is at risk or where the provider has committed fraud, restrictions of coverage will likely need to be immediate.

That said, any restriction of service delivery modes will be exercised judiciously and only applied where the conditions of approval have been breached. In addition, in suspending or revoking an approval, the medical institution concerned must be given written notice and a reasonable opportunity to make representations as to why the approval should not be suspended or revoked, which is already our practice today.

Dr Syed Harun also asked that we engage private medical practitioners to support them in navigating these changes. Indeed, private providers are an important part of our healthcare ecosystem. We will continue to partner and educate them on these changes.

Altogether, the amendments in this category allow MediShield Life to be more flexible and responsive to the evolving healthcare landscape.

The Act also needs to be amended to better support premium recovery. For a universal scheme like MediShield Life, premium recovery is necessary to discourage policyholders who can afford to, but wilfully decide not to fulfil their premium obligations. This in turn keeps the scheme sustainable.

Without a robust set of premium recovery measures, it is entirely possible that premium defaults could go up, translating to bad debts which could materially impact the Fund and result in higher premiums for all. This would be unfair to policyholders who have paid their premiums and undermines collective responsibility.

Over the years, the premium default rate, which is the total premium debt as a proportion of total premiums payable, has remained low, below 1%. This means that the vast majority of the policyholders are able to pay their premiums. This is made possible through a comprehensive support system to help Singaporeans, especially those of less means, with their premiums, thereby reducing the likelihood of individuals defaulting in the first place. I had covered these in detail earlier in my speech.

Even with these support measures, there will be a small group of individuals who do not fulfil their premium obligations. When deduction of the premium from the policyholder's or his designated payor's MediSave fails, the Government embarks on a series of premium recovery measures.

Family members, such as parents and spouses, will be identified to pay for their loved ones' premiums using MediSave, on an opt-out basis. Those notified may choose to cancel this payment arrangement if they do not wish to help with their family members' premiums.

Eligible individuals will also be invited to apply for APS. MOH works with the Ministry of Social and Family Development to conduct proactive outreach to low-income, elderly individuals who may need help with their APS applications.

Quarterly reminder letters are also sent to remind policyholders to top up their MediSave accounts, change the premium payor or arrange for monthly instalment payment plan for their owed premiums.

Significant efforts are made to ensure that those who are genuinely in need receive support to pay their premiums. Only when these efforts are exhausted, would premium enforcement commence.

Before any enforcement action can be taken against defaulters, a demand note must first be served. A demand note notifies defaulters of their outstanding premiums and gives them sufficient time to pay their premiums, before interest and penalties are imposed and further enforcement measures like agent appointments are taken. These measures take reference from income tax recovery measures and are already provided for in the existing legislation.

IRAS, which is a prescribed recovery body under the MediShield Life scheme, sends the demand notes via mail, as provided for under the legislation.

However, there are some defaulters who are difficult to reach via post. This includes individuals who do not update their residential or correspondence addresses with the Government after they renounce their Singapore Citizenship or lose their Permanent Residency status, as well as individuals residing overseas in areas with unreliable postage services.

As demand notes are often not successfully delivered to such individuals, enforcement against this group is limited in effectiveness. Therefore, the Act amendments provide for more avenues through which demand notes may be served, including via digital means. So, to address Mr Gerald Giam's concern, this is actually on top of existing means such as the physical mail. This maximises the likelihood that recovery bodies can serve demand notes on defaulters who do not maintain a valid postal address.

We will leverage on two additional avenues: one, the Bill will provide for demand notes to be served via email; two, the Bill will also empower the Minister to make regulations to allow demand notes to be served via existing electronic service platforms. This could include IRAS' "myTax Portal" and CPF Board's "my cpf" portal. We will work with both agencies to explore the feasibility of tapping on their electronic service platforms. This is a fair approach – Singaporeans already use these portals to manage their tax- and CPF-related matters, and it is reasonable for the Government to make contact with them through such channels.

We will explore with IRAS and CPF Board on the feasibility of sending notifications through SMSes and emails, to ensure demand notes are brought to the attention of the recipients.

As I mentioned earlier, everyone must pay for their premiums as part of our collective responsibility to one another and to ensure the sustainability of the scheme. This is why we have a strong set of recovery and enforcement actions in place.

However, we are mindful that some Singaporeans may face difficulties paying for their premiums due to complex circumstances. Hence, we adopt a compassionate stance towards premium recovery and enforcement. This way, we do not inadvertently cause hardship to those who are unable to meet their premium obligations. For example, we withhold enforcement from vulnerable groups as such elderly above the age of 85 years old.

One proxy for an individual's ability to pay their premiums is their means information. The proposed amendment will support the use of means information to enable a calibration of our premium recovery and enforcement efforts when it comes to Singaporeans with genuine difficulty in affording their premiums.

Mr Yip Hon Weng asked about how such means information would be used, the criteria used to calibrate enforcement efforts and whether such criteria would reduce accessibility for individuals that do not meet the bar. Mr Gerald Giam also raised concern that some Singaporeans with complex circumstances may face difficulties paying premiums and this is precisely why we are creating this avenue to allow for a more calibrated approach.

I would like to assure the Members that the intent of this amendment is not to withhold subsidies and support from Singaporeans. On the contrary, it is meant to help Singaporeans – by ensuring that premium enforcement measures are targeted at those who have more means, while calibrating enforcement measures for those who have less means.

Means information is used to derive per capita household income. This is aligned to many other Government schemes that differentiate subsidies based on PCHI to ensure that resources are targeted at those who need more support. We acknowledge the Members' concern that this may not differentiate retired seniors with different financial situations, including those who are asset-rich and cash-poor. This is why we have APS, which serves as a discretionary safety net, to give support to those who may have fallen through the cracks and face genuine difficulty affording their premiums.

Eligibility for APS is assessed holistically with appeals considered on a case-by-case basis, taking into consideration the unique social and financial circumstances, and needs of individuals.

Individuals receiving APS will have their outstanding premiums, as well as premiums for the next two policy years fully covered. Premium enforcement would not apply to them. For individuals who do not qualify for APS, we will still exercise flexibility for those with extenuating circumstances, on a case-by-case basis. For instance, we may delay premium enforcement until their financial circumstances improve. If some require a longer time to pay their premiums, they may contact the CPF Board, which oversees premium collection, to work out an instalment payment plan.

For premium enforcement, we work with the MediShield Life Council on detailed criteria as well as the appeal guidelines for cases at the margins, to ensure enforcement does not unfairly penalise such groups. Let me take the chance here to reiterate that no one will lose MediShield Life coverage due to an inability to pay premiums.

Besides refining provisions to support premium recovery efforts, we are also making some amendments to clarify and strengthen existing administrative processes.

One such amendment is allowing the MediShield Life premium schedule to be specified on a website rather than in legislation. Mr Yip Hon Weng asked about the potential impact of such a move on our less digitally savvy seniors.

Let me clarify that the amendment is not meant to change anything about how premiums are communicated to Singaporeans. All policyholders will continue to receive a premium notification letter which details their premiums payable and premium subsidy entitlements for a given policy year. These will continue to be delivered through mail, SMS or email, depending on the policyholder's contact information available to the CPF Board. So, Singaporeans, including seniors, already have many platforms through which to access information about premiums, and this amendment will not change this.

Instead, this amendment is simply intended to allow MediShield Life premiums to be published on a website instead of through legislation. In enabling this, we will significantly streamline the administration of the scheme. This is also the approach already in place for other healthcare schemes such as CareShield Life, for which premiums are available online instead of through legislation.

Mr Gerald Giam spoke about the stability and predictability of premium rates. The premiums are already published on the website today and we have also given advance notice for the next policy cycle – it is actually three years' worth of premiums in the press release and also in the Council's report.

To address also another administrative point that Mr Gerald Giam raised on individuals who unknowingly provide false or misleading information – actually, such conduct does not amount to an offence under the Act.

In addition, we fully acknowledge the need to help Singaporeans, especially our seniors, understand the key healthcare policies such as MediShield Life, and changes that are made to them from time to time. So, in addition to ongoing efforts to raise awareness and improve public understanding of MediShield Life, MOH is also working closely with various community partners like grassroots leaders and Silver Generation Ambassadors to engage Singaporeans on the recent changes to MediShield Life. Such efforts allow us to reach more citizens, including seniors, and ensures that no one is left behind.

Let me conclude. The debate has largely focused on how we can ensure that MediShield Life continues to adequately protect Singaporeans against large medical bills, while ensuring that the scheme remains sustainable and premiums affordable for all Singaporeans. This has always been our objective from the initial launch and subsequent reviews of the MediShield Life scheme, and the design of the Act which provides us the legislative framework to operationalise it.

This Bill will strengthen the legislative framework to help us better achieve these objectives by:

Enabling MediShield Life to provide adequate protection as the healthcare delivery landscape evolves from hospitals to the community and home settings;

Providing a clear and robust framework to manage medical institutions participating under MediShield Life to ensure the appropriate use of MediShield Life monies, especially as MediShield Life coverage expands to new treatments and services; and

Facilitating the implementation of premium enforcement measures to ensure that everyone pays their premiums as part of collective responsibility to one another and to ensure the sustainability of the scheme.

I thank Members for their support of this Bill. Mr Speaker, I beg to move.

Mr Speaker: Are there any clarifications for Minister of State? Mr Gerald Giam.

5.23 pm

Mr Gerald Giam Yean Song: I thank the Minister of State for responding to my questions. I just have two main clarifications.

First, the Minister of State assured us earlier that no one would lose MediShield Life coverage due to an inability to pay premiums. How about policyholders who miss payments for reasons such as ineligibility for premium support despite appeals, missed reminders or other issues. Are there any circumstances under which they could lose MediShield Life coverage due to a failure to pay premiums?

Secondly, does the Bill allow the Minister to designate TCM providers as approved providers for the purpose of MediShield Life claims if they need accreditation criteria for TCM practitioners, which I understand from the Minister this morning during Question Time will be ready next year? I know the Minister of State provided a list of conditions in her response just now, but it is not clear if it potentially includes TCM.

Ms Rahayu Mahzam: I thank Member for the query. In respect of the second question – first, I just want to add that the MediShield Life scheme is something that we review and its coverage is something that we will continue to monitor and assess. So, this is something that will allow for us to continue to look at it and if it meets the criteria, it would be something that can be included. This is something that we will look at on a regular basis.

On the assurance, actually, we ensure that people will not lose their coverage because of that. But as I explained, the whole thinking behind this is that there is 1% of those that we are not able to recover from and we just want to ensure that out of this, the people who are doing it out of just not wanting to comply and not wanting to actually make payment are then caught out.

But for those who are actually in really dire circumstances, the processes that I have earlier mentioned will be able to catch them and will ensure that there will be some support given in the event they really cannot pay because of the difficulties.

5.25 pm

Mr Speaker: Any other clarifications? I see none.

Question put, and agreed to.

Bill accordingly read a Second time and committed to a Committee of the whole House.

The House immediately resolved itself into a Committee on the Bill. – [Ms Rahayu Mahzam].

Bill considered in Committee; reported without amendment; read a Third time and passed.