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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

15D. Standards for managed health care


1) If any managed health care is undertaken by the medical scheme itself or by a managed health care organisation, the medical scheme must ensure that:
a) a written protocol is in place (which forms part of any contract with a managed health care organisation) that describes all utilisation review activities, including a description of the following:
i) procedures to evaluate the clinical necessity, appropriateness, efficiency and affordability of relevant health services, and to intervene where necessary, as well as the methods to inform beneficiaries and health care providers acting on their behalf, as well as the medical scheme trustees, of the outcome of these procedures;
ii) data sources and clinical review criteria used in decision-making;
iii) the process for conducting appeals of any decision which may adversely affect the entitlements of a beneficiary in terms of the rules of the medical scheme concerned;
iv) mechanisms to ensure consistent application of clinical review criteria and compatible decisions;
v) data collection processes and analytical methods used in assessing utilisation and price of health care services;
vi) provisions for ensuring confidentiality of clinical and proprietary information;
vii) the organisational structure (e.g. ethics committee, managed health care review committees, quality assurance or other committee) that periodically assesses managed health care activities and reports to the medical scheme; and
viii) the staff position functionally responsible for day-to-day management of the relevant managed health care programmes;
b) the managed health care programmes use documented clinical review criteria that are based upon evidence-based medicine, taking into account considerations of cost-effectiveness and affordability, and are evaluated periodically to ensure relevance for funding decisions;
c) the managed health care programmes use transparent and verifiable criteria for any other decision-making factor affecting funding decisions and are evaluated periodically to ensure relevance for funding decisions;
d) qualified health care professionals administer the managed health care programmes and oversee funding decisions, and that the appropriateness of such decisions are evaluated periodically by clinical peers;
e) health care providers, any beneficiary of the relevant medical scheme or any member of the public are provided on demand with a document setting out –
i) a Clear and comprehensive description of the managed health care programmes and procedures; and
ii) the procedures and timing limitations for appeal against utilisation review decisions adversely affecting the rights or entitlements of a beneficiary; and
iii) any limitations on rights or entitlements of beneficiaries, including but not limited to restrictions on coverage of disease state protocol requirements and formulary inclusions or exclusions