The CEO is the accounting officer exercising overall control over the office of the Council for Medical Schemes, and as Registrar, he exercises legislated powers to regulate medical schemes, administrators, brokers, and managed care organisations.

The CEO and Registrar is responsible for leading the development and execution of the Council for medical schemes strategy. The CEO and Registrar is ultimately responsible for all day-to-day management decisions and for implementing the CMS’ strategic and annual plans therefore there are three new specific objectives or indicators developed for this sub-programme.

Under the leadership of Council, the Office of the CE & Registrar is responsible for the following CMS Outcomes:

The purpose of this programme is to ensure the smooth coordination of the Office of the Chief Executive & Registrar, by ensuring that performance information is reported in accordance with the framework for Strategic and Annual Performance Plans. In addition, the office ensures that an effective and transparent risk management system is maintained to mitigate risk exposure for the entity. Lastly, the programme ensures that strategic relationships with co-regulators and stakeholders are developed and maintained.

The purpose of this programme is to engage in strategic projects as well as to provide information to the Ministry on health reform matters in order to achieve government’s objective of equitable and sustainable healthcare in support of universal access. It strives to provide support to the office of the Registrar on clinical matters so that good quality medical scheme cover would be maximised in order that regulated entities are properly governed, through prospective and retrospective regulations. The unit also undertakes strategic research that would enable the CMS to advise the NDOH on policy initiatives. It provides a mechanism for the CMS to provide support to the NDOH on key policy reforms such as the NHI and HMI.

The Council Secretariat is responsible for the following:

The Office of the Chief Financial Officer (CFO) serves all the business units in CMS, the senior management team and Council by maintaining an efficient, effective and transparent system of financial management that complies with the applicable legislation. They also serve the Audit Committee, Internal Auditors, National Department of Health, National Treasury and Auditor-General by making available to them information and reports that allow them to carry out their statutory responsibilities. By doing this, we help the Council to be a reputable Regulator.

The purpose of the Information Communication Technology and Information Management (ICT & IM) unit is to provide technology enablers and make information available and accessible to ensure the CMS is an efficient and effective regulator of the medical schemes industry. The ICT & KM unit comprises of three sub-units which are Networks, Software Development and Information Management:

Corporate Services encompass the support functions of the organisation: Human Resources, Communications, Marketing & Stakeholder Relations, Legal Services and Facilities Management

Human Resources is committed to providing high quality service to internal and external customers by assessing their needs and proactively addressing those needs through developing, delivering, and continuously improving human resources programs that promote and support Council’s vision.

We will fulfill this mission with professionalism, integrity, and responsiveness by:

By doing this we help the Council for Medical Schemes by supporting its administration and staff through Human Resources Management advice and assistance, enabling them to make decisions that maximize its most important asset: its people and to continue the development of CMS as an employer of choice.

The Unit is responsible for ensuring effective human resource management within CMS by:

The Communications, Marketing and Stakeholder Relations unit aims to create and promote optimal awareness and understanding of the medical schemes environment by all regulated entities, the media, Council members and staff, through communication, marketing and stakeholder management.

The Legal Services Unit provides legal advice and representation to the CMS and business units to ensure the integrity of regulatory decisions.

By doing this they ensure that the Registrar and Council are able to regulate within the powers provided by the Medical Schemes Act.

The duties of the unit are:

The Regulation Division consists of:

1. Accreditation Unit
2. Benefits Management Unit
3. Compliance and Investigations Unit
4. Financial Supervision Unit

The Accreditation Unit serves beneficiaries of medical schemes, brokers, broker organisation, administrators and managed care organisations by assessing the extent to which these entities meet the accreditation requirements set out for accreditation by the Medical Schemes Act, including whether applicants are fit and proper, have the necessary infrastructure and are financially sound. Self-administered schemes that provide administration and/or managed care services are similarly evaluated for compliance with the relevant standards. We ensure that team members provide ongoing support and communicate efficiently and effectively to all stakeholders.

The Benefits Management Unit serves beneficiaries of medical schemes and the public in general by reviewing and approving changes to contributions paid by members and benefits offered by schemes.

We analyse and approve all other rules to ensure consistency with the Medical Schemes Act. This ensures that the beneficiaries have access to affordable and appropriate quality health care. By doing this we help the Council for Medical Schemes ensure that the rules of medical schemes are fair to beneficiaries and are consistent with the Act. The unit’s core focus is to assist the Council for Medical Schemes in ensuring that the rules of medical schemes are fair and are consistent with the Act.

The unit serves the beneficiaries of medical schemes and the public by:

This ensures the protection and fair treatment of beneficiaries and that the beneficiaries have access to affordable and appropriate quality health care.

Compliance and Investigations serve members of medical schemes and the public in general by analysing, reviewing and investigating information on possible transgressions of the Medical Schemes Act and taking appropriate actions to enforce compliance with the Act.

By doing this we help the Council for Medical Schemes foster compliance with the Medical Schemes Act and take proportionate actions to promote a culture of compliance with legislation.

The Compliance & Investigations unit ensures that schemes, administrators and brokers comply with the Medical Schemes Act and regulations, specifically in respect of the areas designated by the office as priority areas namely, non-healthcare expenditure, governance, general non-compliance, the risk assessment framework, enforcement of rulings made by the Registrar and the demarcation between medical schemes and insurers.

The Compliance & Investigations unit does that by:

Financial Supervision serves beneficiaries of medical schemes, the Registrar’s office and trustees by analysing and reporting on the financial performance of medical schemes and ensuring adherence to the financial requirements of the Act.

By doing this, they help the Council for Medical Schemes monitor and promote the financial performance of schemes in order to achieve an industry that is financially sound.

The staff of the unit is made up of four Chartered Accountants, and other financial analysts. This cost centre is responsible for:

Clinical Services is responsible for formulating Prescribed Minimum Benefits (PMBs) definitions to ensure members are adequately protected and to provide clinical opinions with a view to resolving complaints and enquiries. The unit plays a lead in the:

The Complaints Adjudication Unit serves beneficiaries of medical schemes and the general public by investigating and resolving complaints in an effective, efficient and fair manner. By doing this, it ensures that beneficiaries are being treated fairly by their medical schemes.

This Unit serves the beneficiaries of medical schemes and the general public by investigating and resolving complaints and disputes lodged against medical schemes.

Amongst other duties, the Unit is also responsible for the following:

The Education and Training sub-unit serves members of medical schemes and the public in general by providing training and education interventions in order to increase understanding of medical schemes by consumers and promote good corporate governance from trustees.

By doing this they help the Council for Medical Schemes to promote understanding of the medical schemes environment by trustees, beneficiaries, and the public.

The Unit offers the following programmes as part of Consumer Awareness and Education Initiatives

For more detailed information on what this unit does, click on the consumer assistance and then on consumer education.

The Customer Care Centre Unit aims to create and promote stakeholders optimal awareness and understanding of the medical schemes environment through customer care interventions.

The Research and Monitoring Unit serves beneficiaries of medical schemes and members of the public by collecting and analyzing data to monitor, evaluate and report on trends in medical schemes and develop recommendations to improve the regulatory policy and practice.

By doing this they help the Council for Medical Schemes to contribute to the development of policy that enhances the protection of the interests of beneficiaries and members of the public.

The Research and Monitoring Unit comprises a team of multidisciplinary professionals with skills in health economics, statistics, epidemiology, public health, and financial analysis.

The team is responsible for monitoring the impact of the Act, researching developments and recommending policy options to the Department and Ministry of Health, to improve the regulatory environment.

Research conducted by the unit currently covers the areas of utilisation of health care services in the private sector, strengthening governance in medical schemes by proposing a framework for trustee remuneration and development of a process for measuring quality and outcomes in the private health care sector. Research methods include a combination of literature reviews, consultative processes, surveys, and statistical tools. Research output is often disseminated to the medical schemes industry through the publication of monographs and presentations at industry consultative forums.

The unit also analyses the non-financial portion of the statutory returns from medical schemes which focuses on geographic, demographic, and health care utilisation indicators. This contributes to the production of quarterly and annual reports of the Registrar of Medical Schemes. Several research reports are currently available that have been generated by the unit some of which can be found on the publications portal of the CMS website. Others can be obtained on request from the Council.