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Council for Medical Schemes

Council for Medical Schemes. Who is the Council for Medical Schemes (CMS). Regulatory authority Administers and enforces Medical Schemes Act (Act 131 of 1998) Independent public agency Bound by the Act. The Role of CMS. A Number of Statutory Objectives including but not limited to:

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Council for Medical Schemes

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  1. Council for Medical Schemes

  2. Who is the Council for Medical Schemes (CMS) • Regulatory authority • Administers and enforces Medical Schemes Act (Act 131 of 1998) • Independent public agency • Bound by the Act

  3. The Role of CMS A Number of Statutory Objectives including but not limited to: • The protection of the interests of medical schemes and their members (No discrimination) • To control and co-ordinate the functioning of medical schemes in a manner that is complementary with the national health policy • To investigate complaints and settle disputes in relation to the affairs of medical schemes

  4. Rules of a Medical Schemes • Each Medical Scheme should have registered rules • Provide for scope and level of minimum benefits • CMS - Benefit Management Unit • Reviewing and • Approving changes • Contributions paid by members • Benefits offered by schemes. • Fair to beneficiaries • Consistent with the Medical Schemes Act. • Rules are binding to all members

  5. Prescribed minimum benefits • An exclusive list of 270 conditions / groups of conditions, in the form of diagnosis and treatment pairs that medical schemes are compelled to pay for. • Any emergency condition • 26 Chronic conditions (CDL): The entitlement included “Diagnosis, medical management and medication, to the extent that this is provided for by way of a therapeutic algorithm for the specified condition, published by the Minister by notice in the Gazette.” • Scheme may not exclude PMB in its rules.

  6. Disabled person and Medical Scheme benefits • Rules of a Scheme guide to entitlement • Hearing aids • Visual aids • Appliances • At least provide for PMB’s • Non-PMB’s may or may not be provided for • Example: Spinal cord injury - difficulty in breathing, eating, swallowing, and bowel or bladder control

  7. Complaints adjudication at CMS • Investigating and resolving complaints and disputes lodged against medical schemes. • Dedicated complaints and adjudication division assisted by a legal and a clinical team. • CMS provide assistance in investigating and resolving complaints in accordance with the provisions of the Act.

  8. The End

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