Circular 19 of 2021: Expanded scope of practice of optometry service providers

Background

1. The Minister of Health, Dr Zweli Mkhize, in terms of section 22a(2) of the Medicines and Related Substances Act, 1965 (Act no 101 of 1965) (“the MSRA”) updated Schedules 1 to 4 to the MSRA. Annexure 3 to the Schedules relate specifically to what optometrists may prescribe and supply in line with their scope of practice.
2. Accordingly, the Health Professions Council of South Africa (“HPCSA”) approved the expansion of the scope of practice of optometrists concerning consultations and/or medication related to ocular therapeutics. Such optometrists must be registered with the Health Professions Council of South Africa (“HPCSA”) in terms of the Health Professions Act, 1974 (Act no 56 of 1974) and must be in possession of a permit as provided for in section 22A(15) of the MSRA.
3. The Board of Healthcare Funders (“BHF”) consequently enhanced the Practice Code Numbering System (“PCNS”) in terms of amending the practice numbers of optometrists who have therapeutic privileges to enable stakeholders in identifying same and fund claims appropriately (where applicable).

Inappropriate rejection of or short payment of optometry claims relating to the expanded scope of practice (where applicable)

4. It has come to CMS’ attention that optometry claims relating to the expanded scope of practice are in some instances being inappropriately rejected or short paid by medical schemes.
5. The cause of the rejections or short payments of claims is unclear, but the CMS is urging all stakeholders (medical schemes, administrators, managed care organisations and clearing houses/switches), to ensure that their processes, systems, policies, etc. are aligned to these changes where appropriate. This is in cases where registered scheme rules provide for such benefits or they fall within the Prescribed Minimum Benefits (PMBs).
6. Medical schemes with benefit design offering offer optometry benefits, should ensure that the registered rules of the schemes appropriately provide for the enhanced scope of practice consultations/prescribed medications provided and/or prescribed by qualifying optometrists, and as provided for in Section 57(4)(h) of the Medical Schemes Act. PMB claims that are in line with the expanded scope of practice (in terms of qualifying optometrists with therapeutic privileges), should still be funded as PMBs and as provided for in the scheme rules.

Download the Circular here