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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

15E. Provision of health services


1) If managed health care entails an agreement between the medical scheme or a managed health care organisation, on the one hand, and one or more participating health care providers, on the other –
a) the medical scheme is not absolved from its responsibility towards its members if any other party is in default to provide any service in terms of such contract;
b) no beneficiary may be held liable by the managed health care organisation or any participating health care provider for any sums owed in terms of the agreement;
c) a participating health care provider may not be forbidden in any manner from informing patients of the care they require, including various treatment options, and whether in the health care provider’s view, such care is consistent with medical necessity and medical appropriateness;
d) such agreement with a participating health care provider, may not be terminated as a result of a participating health care provider –
i) expressing disagreement with a decision to deny or limit benefits to a beneficiary; or
ii) assisting the beneficiary to seek reconsideration of any such decision;
e) if the medical scheme or the managed health care organisation, as the case may be, proposes to terminate such an agreement with a participating health care provider, the notice of termination must include the reasons for the proposed termination.


2) A managed health care organisation or a medical scheme, as the case may be, may place limits on the number or categories of health care providers with whom it may contract to provide relevant health services, provided that –
a) there is no unfair discrimination against providers on the basis of one or more arbitrary grounds, including race, religion, gender, marital status, age, ethnic or social origin or sexual orientation; and
b) selection of participating health care providers is based upon a clearly defined and reasonable policy which furthers the objectives of affordability, cost-effectiveness, quality of care and member access to health services