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Press Release 1 of 2021: COVID-19 vaccine and the medical schemes industry

The Council for Medical Schemes (CMS), in executing its mandate as the medical schemes regulator, has been co-ordinating public-private sector collaborations aimed at ensuring that there is universal access to the COVID-19 vaccine, in line with the country’s priorities and individual health needs.

As such, the COVID-19 vaccine has been included in the amended Prescribed Minimum Benefit regulations, approved by the Minister of Health Dr Zweli Mkhize, recently.

This amendment includes the insertion of the Diagnosis and Treatment Pair in the list of Prescribed Minimum Benefits under the heading “Respiratory System” Treatment: screening, clinically appropriate diagnostic tests, vaccination, medication, medical management including hospitalisation and treatment of complications, and rehabilitation of COVID-19.

The CMS has been in continuous engagements with the National Department of Health and industry associations such as the Health Funders Association (HFA) and the Board of Health Funders (BHF), which have supported an approach that seeks to ensure universal access, provisioning and availability of the COVID-19 vaccine, for those that are prioritised.

The public-private collaborative approach is aimed at supporting the national effort of achieving a herd immunity of 67% and more through the equitable access to the vaccine, particularly because the COVID-19 pandemic is a national and international public health crisis that affects all.

The CMS acknowledges that there may be an additional cost burden to medical schemes for the provision of the vaccine, but this is not expected to be prohibitively high. In addition, industry associations have assured the CMS that vaccine costs can be absorbed by most medical schemes.

The Minister of Health has directed the CMS continue engagements with the medical schemes and associations in the quest to develop a detailed framework that will guide the industry and the members of the public on this concession.

There are several issues which need further exploration and discussion before there is agreement on them. These include the development of:

  • A clear criteria on prioritised populations
  • Clinical guidelines and protocols
  • Guidelines on medical scheme liquidity management and scheme reserve requirements
  • The vaccine funding model and mechanism
  • The appropriate funding vehicle
  • Governance processes for the prevention of Fraud, Waste and Abuse
  • Possible exemption of the COVID-19 vaccine from single exit price (SEP) requirements

Whilst these engagements are ongoing, the CMS, in line with its mandate, will continue to ensure that the rights of medical scheme members are protected at all times.

Download the Press Release here.