The Council for Medical Schemes is a statutory body established by the Medical Schemes Act (131 of 1998) to provide regulatory supervision of private health financing through medical schemes. Governance of the Council is vested in a board appointed by the Minister of Health, consisting of a Non-executive Chairman, Deputy Chairman and 13 members. The Executive Head of the Council is the Registrar, also appointed by the Minister in terms of the Medical Schemes Act. The Council determines overall policy, but day to day decisions and management of staff are the responsibility of the Registrar and the Executive Managers. The Council supervises a massive and very important industry comprising more than 80 medical schemes registered in the country.
To be an agile and transformative regulator in order to promote affordable and accessible healthcare cover towards universal health coverage.
The CMS regulates the medical schemes industry in a fair and transparent manner and achieves this by:
- protecting the public and informing them about their rights, obligations and other matters, in respect of medical schemes.
- ensuring that complaints raised by members of the public are handled appropriately and speedily.
- ensuring that all entities conducting the business of medical schemes, and other regulated entities, comply with the Medical Schemes Act.
- ensuring the improved management and governance of medical schemes.
- advising the Minister of Health of appropriate regulatory and policy interventions that will assist in attaining national health policy objectives.
- ensuring collaboration with other stakeholders in executing its regulatory mandate.
The values of the CMS stem from those underpinning the Constitution and its specific vision and mission. Being an organisation that subscribes to a rights-based framework where everyone is equal before the law, where the right of access to health care must be protected and enhanced, and where access must be simplified in a transparent manner, the values below are key requirements of all employees:
|Regulatory philosophy (external)||Shared values (internal)|
Goal 1: Access to good quality medical scheme cover is promoted
The aim of this goal is to ensure that beneficiaries of medical schemes receives adequate and quality health care cover. To grow membership of medical schemes in order to increase the percentage of the population covered by medical schemes. As CMS we create an enabling environment that is conducive for schemes to grow membership. Currently only about 17% of the population is covered by medical schemes. If membership of schemes is increased the burden in public sector facilities will be alleviated.
CMS will ensure that at all times barriers to scheme access are minimized and that coverage provided by schemes is of a high standard. Improved risk pooling is achieved through enhanced community rating, open enrolment, and prescribed minimum benefits.
The process of evaluating the clinical effectiveness and value proposition of managed care activities provided to medical schemes is in the process of being strengthened by introducing entry level criteria, process indicators and outcomes for treatment of patients with one or more chronic disease conditions. The process provides for participation by role-players and once introduced, will significantly enhance the ability to evaluate the health outcomes in terms of resources employed and price paid for such services.
CMS will publish Prescribed Minimum benefit definitions and CMScript articles as guidelines to inform the industry and members of appropriate treatment plans. These guidelines will clarify what PMB entitlements entail and as such provide guidance to the healthcare industry on funding of PMBs with the resultant effect that complaints with regards to these conditions are minimized.
CMS must ensure that scheme rules are registered to cover the required health care benefits and contribution increases and are reviewed to ensure cost effectiveness and affordability.
CMS will collect process and outcomes indicator data through the Annual Statutory system for various chronic diseases at benefit option level. The analysis of the data will aim to measure health quality outcomes at benefit option level that could be linked to the performance of specific managed care entities.
CMS will also continue to put measures in place to measure and monitor financial soundness of medical schemes. This ensures that schemes will be able to meet their financial obligations.
Goal 2: Medical schemes and related regulated entities are properly governed, responsive to the environment and beneficiaries are informed and protected
Ensure that at all times medical schemes are governed in the interests of beneficiaries by ensuring that the principles of good corporate governance are fully adhered to and that appropriate action is taken against corporate governance failures.Ensure that Medical Schemes and other regulated entities are compliant with the Medical Schemes Act and other relevant legislation. Create an environment where members actively participate in the affairs of their scheme.
By 2020, amendments to the Medical Schemes Act must be in place to strengthen governance provisions, appeals processes, enforcement powers and complaints resolution processes.
Ensure that at all times medical schemes are sensitive to the specific needs of beneficiaries, are financially sound, offers protection against catastrophic financial incidents.Schemes must also be sensitive to broader social considerations through the introduction of appropriate regulatory measures such as fair treatment of beneficiaries.
CMS is looking at a risk based solvency framework that will go a long way in changing the landscape in medical scheme environment. Medical schemes are currently required to maintain accumulated funds expressed as a percentage of gross annual contributions which may not be less than 25%. There have often been debates and challenges to this regulation and the somewhat undesirable effects of the manner in which the solvency ratio is calculated. In order to fully understand the matter and related consequences, the CMS will undertake a research project that would begin to respond to these challenges.
By 2020 the Council must have a well-functioning system to cater for the electronic filing of scheme rules, and a well-functioning composite risk index system.
Through the control and coordination of the availability of information emanating from regulated entities, their education and training activities, participation in public discussions, and the publication of material in lay and official publications, the CMS will contribute to ensure that members, their dependents, and the public are informed of their rights.
Enhance visibility of CMS as a brand through campaigns and advertising.
The communication guidelines and model rules have been developed are continuously being enhanced to ensure that schemes are aware of the information that must be sent to members. The model rules are a guide to the form and structure of the rule which schemes are encouraged to adhere to; to ensure the protection of members rights through clarity of disclosure. The communication guidelines will ensure that there is improved communication between CMS and the schemes such that information is disseminated with ease to members.
CMS has issued trustee remuneration guidelines, this will go a long way to guide trustees in their fiduciary responsibilities. CMS further conducts investigations where governance irregularities are identified and in some instances this leads to some schemes being put under curatorship.
CMS will also have to ensure that a Practice Code Numbering system is administered by an approved entity in order to facilitate claims payment and resource planning.
CMS will ensure that brokers and broker organisations, administrators and managed care organisations are accredited in line with the accreditation requirements as set out in the Medical Schemes Act, ensuring that applicants are fit and proper, have the necessary resources, skills, capacity, and infrastructure and are financially sound. Protection of beneficiaries is key to our regulatory function and the complaints resolution process must be improved continuously to instill confidence in beneficiaries that their complaints will be resolved timeously. A system of alternative dispute resolution has been put in place to assist in the complaints resolution. This will be monitored in the MTE years to ascertain the impact this has on the complaints resolution process.
Goal 3: CMS is responsive to the environment by being a fair, transparent, effective and efficient organisation
Through the improvement of:
- business processes and business process automation
- information collection and dissemination.
- financial and other best practice monitoring systems.
- Information Technology (IT) systems.
- human resource policies and procedures and strategies developed for staff retention and human capital investment.
- financial management.
- legal advisory services.
- operational efficiency.
The CMS will constantly adapt to the ever-changing environment and will improve its way of doing business.
To improve its efficiency over the MTE period, the CMS will invest in its IT infrastructure. The area of supply chain management will be strengthened. CMS will ensure that it applies corporate governance principles in its operations. CMS will ensure that it deals with stakeholders in a fair and transparent manner.
Goal 4: CMS provides strategic advice to influence and support the development and implementation of National health policy
Through reviewing the needs of the environment, the CMS, will constantly collect and upgrade the collection of information for the purposes of an ongoing and strategic review of the private health system including advising on relevant legislative reform.
Research is conducted on aspects of the health system that have an impact on medical schemes and beneficiaries. CMS collects and analyses healthcare utilisation data through the Annual Statutory Returns and makes recommendations to the Registrar on significant trends in the industry which may have an impact on National Health Policy.
Through the development of application systems such as the Single Exit Price (SEP) and Beneficiary Registry, the CMS will assist NDoH to attain its objective of an efficient health management information system for improved decision making, planning, and policy implementation.
Through its strategic position in the health system, the CMS will form strategic relations with regional and international institutions, consult, research, and collate information for the purposes of influencing stakeholders and to provide strategic advice to Government; as well as provide technical assistance to major strategic health reforms like the NHI.