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Medical Schemes Act, 1998 (Act No. 131 of 1998)


Regulations in terms of the Medical Schemes Act

Chapter 5 : Provision of managed health care

15A. Prerequisites for managed health care arrangements


1) If a medical scheme provides benefits to its beneficiaries by means of a managed health care arrangement with another person –
a) the terms of that arrangement must be clearly set out in a written contract between the parties;
b) with effect from 1 January 2004, such arrangement must be with a person who has been granted accreditation as a managed health care organisation by the Council; and
c) such arrangement must not absolve a medical scheme from its responsibility towards its members if any other party to the arrangement is in default with regard to the provision of any service in terms of such arrangement.


2) To the extent that managed health care undertaken by the medical scheme itself or by a managed health care organisation results in a limitation on the rights or entitlements of beneficiaries, the medical scheme must furnish the Registrar with a document clearly stating such limitations, which document must be resubmitted to the Registrar within 30 days of any amendment to such limitations taking effect, including the relevant amendments.


3) Limitations referred to in subregulation (2) include, but are not limited to restrictions on coverage of disease states, protocol requirements, and formulary inclusions or exclusions.