With about 97 medical funds currently operating in South Africa boasting over 8 million beneficiaries, there was need to have legislation in place to ensure these schemes are regulated. This came in the form of the 1998 Medical Schemes Act No. 131. The Council for Medical Schemes is the statutory body that was created to implement regulatory requirements contained in the act. This body is governed by a 13-member board, all appointees of the government; the Ministry of Health more specifically. The council has a Registrar who is more or less the body’s CEO who is aided by a number of executive managers.

Council roles

One of the key roles of the council is the resolution of disputes arising from complaints of medical scheme members. These are of course complaints that a member has raised with his medical cover provider and not received a satisfactory response. And should the verdict issued by the council not appear just to the complainant, they can appeal the decision to the Appeal Board. But this will cost them a little extra. The ultimate aim is to ensure medical scheme members get value for their money and are treated fairly by the medical scheme companies. But the resolution of policy disputes is just one facet of the Council for Medical Schemes mandate. The body also upholds the interests of the medical schemes but only for as long as they are operating within the national health policy. Monitoring the financial status of every medical scheme also falls within the council’s docket, ensuring the schemes are financially sound enough to process claims whenever they’re obligated to. The council also acts to level the playing field for medical scheme providers by ensuring they all conform to the Medical Schemes Acts. This is done by reviewing and approving the contributions levied by these providers in the packages they offer the public against the stipulated benefits. The registration of new schemes is also overseen by the Council for Medical Schemes. The council provides accreditation to those schemes and managed care organisations that it has found to fulfil the standards and service levels set by its accreditation unit. Organisations must prove themselves financially sound and have adequate infrastructure to serve members to receive accreditation.

Custodians of medical scheme info

The council also acts as an instrument through which the government disseminates information about healthcare to the public. It makes information accessible to all interested parties including medical scheme providers and members as well as medical insurance brokers. This is part of the body’s own objectives as specified in the Promotion of Access to Information Act. Two arms help the Council for Medical Schemes accomplish this duty; its IT and Knowledge management unit and the knowledge and records management office. Among the many channels used to keep the public updated are RSS feeds that anyone can subscribe to. Additionally, trainings to sensitise the public and medical policy holders on the intricacies of medical schemes are organised by the council’s Education and Training Unit. These trainings consist of workshops, presentations and public awareness drives.

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