Management & Business Units
The CMS executive management is composed of the following structure and business units
The Office of the CEO
CEO & Registrar
Dr Sipho Kabane
Chief Executive and Registrar
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’s 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:
|Outcome 1||To promote the improvement of quality and the reduction of costs in the private health care sector|
|Statement||The high costs of health care services in the private sector has been identified as one of the key factors that affects the sustainability of medical schemes in the short to medium term. The CMS is mandated to collect quality data from the private sector and advise the Health Ministry regarding the appropriate policy interventions. The CMS has to collect all the data on both quality and costs in order to determine if scheme members are getting value-for-money in the many health programmes that they belong to. The CMS supports the increased utilisation of Alternative Reimbursement Models Compared to Fee-for-Service Arrangements coupled with contracting for better outcomes between Schemes and Managed Care Organisations, as well as between Medical Schemes and Healthcare Providers.|
|Outcome 2||To encourage effective risk pooling|
|Statement||Through the standardisation of scheme options, the consolidation of medical schemes with less than 6000 members; the consolidation of government funded schemes, risk based capital solvency framework and the development of a comprehensive Primary Health Care benefit package, the CMS will ensure effective risk pooling and will be measuring the impact of co-payments exposure to beneficiaries. This work will be done through a consultative approach and by being mindful of the risks to scheme members, employers, trade unions and other key stakeholders.|
|Outcome 3||To ensure that all regulated entities comply with, National Policy, the MSA and Regulations|
|Statement||Through ensuring that all entities that are doing the business of a medical scheme are registered or accredited as per the requirements of the Medical Schemes Act, its Regulations and National Policy Interventions. The approval of scheme rules and options; efficient and expedient management of complaints; conducting the necessary inspections, examining all schemes to ensure that they are compliant with the financial requirements including solvency and the effective defence and litigation against errant regulated entities, the CMS will provide members of schemes with the protection they need.|
|Outcome 4||To be a more effective and efficient organisation|
|Statement||Through the review, updating, development and implementation of policies, strategies and standard operating procedures for the Office of the CEO, Office of the CFO, Information Communication and Technology (ICT), Human Resources (HR), Finance, and Legal support sub-programmes, the effectiveness and efficiency of the organisation will be improved. CMS will promote ethical and effective leadership through training, policies and incentivisation.|
|Outcome 5||To conduct policy driven research, monitoring and evaluation of the medical schemes industry to facilitate decision-making and policy recommendations to the Health Ministry|
|Statement||The refocussing of our research efforts and aligning them with the policy developments in the public and private health sectors will ensure that this Outcome is achieved. There will be a need to reprioritise the outputs of the Research and Monitoring, as well as the Strategy office programmes to gain synergies on the one hand and avoid duplications, on the other hand. These research efforts should through partnership with other research institutions support both internal and external stakeholders in understanding the strategic trajectory of the CMS.|
|Outcome 6||To collaborate with local, regional and international entities|
|Statement||The establishment of formalised agreements, attendance of regular meetings and scheduled visits to local, regional and international regulatory authorities will ensure that the CMS is recognised by key regulators as an effective and efficient sector regulator.|
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 Clinical Unit of the CMS is located within this office, and part of its functions is to: Formulate Prescribed Minimum Benefits (PMBs) definitions to ensure members are adequately protected, and to Provide clinical opinions with a view to resolve complaints and enquiries.
Ms Mumsy Mashilo
Acting General Manager: Complaints Adjudication
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:
- Monitoring the fair treatment of members and ensuring that members have access to the benefits provided for in the rules of medical schemes;
- Monitoring compliance with the Medical Schemes Act and the registered rules of medical schemes;
- Providing legal certainty and consistency on decisions issued on complaints.
Dr Olurotimi Modupe
Senior Manager: Clinical Unit
The unit is lead in the:
- Revision of the PMB benefit package;
- Clarification of Scheme member’s benefit entitlements and publication of PMB benefit guidelines;
- Provision of Clinical Opinions for the resolution of complaints by members and beneficiaries of medical schemes;
- Publication of scheme member’s educational materials on PMB entitlements.
Mr Khayalethu Mvulo
The Council Secretariat is responsible for the following:
- The provision and management of corporate governance in the organisation
- Administration of governance Committees such as the Audit & Risk Committee, Human Resources, Social Responsibility & Ethics Committee, EXCO, ICT Governance Committee as well as the Nominations Committee.
- Administration of the dispute resolutions forums of the Council, i.e. the Appeals Committee and the Appeal Board
- Supports the CEO/Registrar in the development of the Strategic Plan and Annual Performance Plans
ICT & Knowledge Management
Mr Ephraim Tlhako
Chief Information Officer: ICT & Knowledge Management
The purpose of the Information & Communication Technology and Knowledge Management (ICT & KM) unit is to provide technology enablers and making 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 Knowledge Management:
- Networks sub-unit is responsible for the provisioning of a robust and secure ICT infrastructure and IT support.
- Software Development sub-unit is responsible for the development and maintenance of innovative business applications to improve efficiencies and service quality.
- Knowledge Management sub-unit is responsible for the handling of all information requests and ensuring information is available and accessible to internal and external stakeholders.
Office of the CFO/Internal Finance
Ms Andisa Zinja
Chief Financial Officer
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.
This Unit provides support to the strategic aims of the Council by way of maintaining an effective, efficient and economic system of financial management.
The Unit also maintains the payroll system which complies with relevant statutes, like the Unemployment Insurance fund Act, SDL and the Income Tax Act.
The Unit achieves its Strategic Aims by:
- Maintaining proper books and accounts;
- Maintaining internal control procedures;
- Ensuring that our assets are insured at all times;
- Regular updating of our financial, payroll and fixed asset systems to keep pace with technological change
Human Resources Management
Ms Agnes Sethogoa
Acting General Manager: Human Resources 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:
- Treating all our customers with respect
- Providing resourceful, courteous, and effective customer service
- Promoting teamwork, open and clear communication, and collaboration
- Demonstrating creativity, initiative, and optimism
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:
- Developing policies and programmes to position the Council as an employer of choice
- Recruitment of appropriately qualified professionals
- Strengthening of employment equity in the work place
- Enhancing performance management and skills development
Ms Mmatsie Mpshane
Acting General Manager: Stakeholder Relations
The 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, education, training and customer care interventions.
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:
- Capacity building workshops,
- General public awareness drives, and
- Awareness presentations.
Ms Silindubuhle Mnqeta
The Communications Unit aids in creating optimal awareness and understanding of regulatory and policy developments and industry trends in the medical schemes environment among principal officers, trustees, beneficiaries, the media, Council members and staff, and other stakeholders.
Customer Care Centre
Ms Nokhanyiso Mini
Manager: Customer Service
The Customer Care Centre Unit aims to create and promote stakeholders optimal awareness and understanding of the medical schemes environment through customer care interventions.
Mr Mashilo Leboho
Acting General Managaer: Benefits Management
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:
- Reviewing and approving changes to contributions paid by members relative to benefits being offered by medical schemes;
- Reviewing and of approval of benefit options and benefits offered by medical schemes;
- Ensuring compliance by all schemes in their rules with the Act, regulations and monitoring of marketing material;
- Reviewing and managing the registration of new schemes; and
- Reviewing and managing the amalgamation and liquidation process in terms of the Medical schemes Act.
This ensures the protection and fair treatment of beneficiaries and that the beneficiaries have access to affordable and appropriate quality health care.
Ms Florence Maphanga
Acting General Manager: Accreditation
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.
By doing this we contribute towards the Council for Medical Schemes objectives by ensuring that regulated entities are properly governed, responsive to the environment, and beneficiaries are informed and protected.
The unit’s role is to:
- Accredit brokers, broker organisations, administrators of medical schemes, and managed care organisations.
- Issue self-administered schemes with compliance certificates with regards to their compliance with the administration and/or managed care standards.
- Investigate matters of non-compliance against accredited entities listed above.
- Develop standards, criteria, and service level agreements for accredited entities and self-administered schemes (where applicable).
- Ensure compliance by accredited entities and self-administered schemes with conditions imposed
- Render advisory services with regards to accreditation matters.
Compliance and Investigations
Mr Mfana Maswanganyi
Acting General Manager: Compliance & Investigations
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:
- Conducting inspections of regulated entities;
- Monitoring compliance of annual and general scheme meeting;
- Communicating with schemes, administrators and brokers on an ongoing basis;
- Engaging the above in dialogue and discussions in respect of contentious/priority areas;
- Training of Boards of Trustees; and Information sessions for Health Providers.
- Take specific enforcement actions.
Mr Sameer Rajab
Acting General Manager: Financial Supervision
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:
- Monitoring the solvency and financial soundness of medical schemes.
- Analysing financial data of medical schemes, reporting the findings therefore and ensuring adherence to the financial requirements of the Act.
Mr John Letsoalo
Acting General Manager: Legal Services
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:
- Provision of legal support to CMS and the Office of the Registrar
- Facilitation of judicial process in matters concerning the enforcement of the Medical Schemes Act
- Investigating inconsistencies with the Medical Schemes Act
- Ensuring that the provisions of the Act are interpreted and applied correctly
Research & Monitoring
Mr Michael Willie
General Manager: Research & Monitoring
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.