03 - Medical Schemes Flashcards
What is Managed HealthCare (MHC)?
Clinical and financial risk assessment and management of health care, with a view to facilitating:
Appropriateness and Cost-effectiveness;
Of relevant health services;
Within the constraints of what is affordable;
Through the use of rule-based and clinical management-based programmes.
What is a MCO (Managed Health Care Organisation)?
A “Managed Health Care Organisation” (MCO) refers to an organization:
That has been accredited through the appropriate procedures by the Council as a MCO and doing the business of managed care;
Had been contracted with a medical scheme in terms of regulation 15A to provide a managed health care service.
Accreditation to a MCO is granted for a period of 2 years.
What factors impacts on the Clinical Risk, claims experience and contribution of a medical scheme?
Member
- Age
- Burden of Disease
- Member / dependant ratio
Scheme
- Nature of Scheme – Open or Restricted
- Utilization of services
- Solvency level
What are the services that are often include in MHC (Managed Health Care)?
Hospital Risk Management
- Pre-Authorisation
- Case management
Disease management programs
- Diabetes
- Asthma
- HIV and AIDS
- Oncology
Pharmacy benefit management
- Authorisation of medicine
- Formulary management
Provider Relations
- Networks
- Fee negotiations
What is the objective of Disease Management Programs?
These programs focus on achieving:
Optimal clinical control of common, high financial impact, chronic diseases.
The disease management protocols use evidence-based clinical treatment guidelines in the programs.
How do members avoid disputes?
Understand the rules of your medical scheme.
Study your benefits guide.
Familiarise yourself with the terms and conditions of the benefit options you have chosen.
Pay your contributions in full and on time every month.
Read all the correspondence.
How do members resolve their disputes?
Speak with your medical scheme first. The law requires all schemes to establish dispute resolution committees.
Give full details of your complaint and include any supporting documents.
If you are not satisfied with the outcome of your complaint to the scheme, lodge a written complaint to the Registrar of Medical Schemes at the CMS.
There are a number of ways to contact the CMS.
If you feel aggrieved by the decision of the Registrar, appeal his/her decision to the Appeals Committee of the CMS.
If you feel aggrieved by the decision of the Appeals Committee of the CMS, appeal to the Appeal Board.
Rules of the Appeal Board can be appealed to the High court.
How will your dispute handled within the medical scheme?
Complain to Principle Officer
Then to Scheme Dispute Committee
- 3 members
- Members must not be Board members, employees, or representatives of the administrator
- They must serve at least 3 years
- At least one of the members must be a legal professional
Thereafter, appeal to the CMS
What do sections 47, 48 and 50 of the Medical Schemes Act say about disputes?
Sec 47: Complaint to Council
- Complaints in writing to registrar
- Registrar to furnish party with detail
- Written response within 30 days
- Registrar resolve the complaint/matter or refer to Council
Sec 48: Appeal to Council
- Anyone aggrieved by decision of Registrar
- Within 3 months
- Registrar’s decision suspended pending outcome
Sec 50: Appeal Board
- 3 Persons - Appointed by Minister
- Anyone aggrieved by decision of the Council or Registrar
- Within 60 days and upon payment of prescribed fee
Why is it important to clearly define the business of a medical scheme vs. that of health insurance?
To ensure that the risk-rated insurance environment does not attract only the young and healthy. This may impact and dilute the principle of social solidarity that underpins medical scheme.
The concern that the public may be unaware of the subtle differences between a health insurance and medical scheme product regarding the level of protection.
What are the key differences between Health Insurance and Medical Scheme benefits?
In the 2004 agreement between LOA, FSB and CMS:
Products operate under different legislation:
- Long-term and Short-term Insurance Act
- Medical Schemes Act
Regulatory body:
- Financial Services Board
- Council for Medical Schemes
Triggers
- “Health Insurance” based on a “health event” (Triggered by a diagnosis of a health condition)
- Triggered by obtaining a relevant health service
Policy benefit
- “one or more sums of money, services or other benefits including an annuity”
- Reimbursement for actual expenditure or part thereof for health services obtained (indemnity business)
Underwriting
- Allowed; can risk-rate
- Not allowed; cannot risk-rate
Product
- Based on a health event
- Based on services obtained
Paid out to
- Policyholder
- Service provider
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Major Feature differences
- Health Insurance Products: Link between health insurance
benefits and actual medical expenses:
- May not provide benefits that are linked to lists of tariffs;
- May pay out a percentage of the sum for which a policyholder is assured, depending on the severity of the health event;
- May pay out benefits on a periodic basis;
- Benefits are paid to the policyholder and not to a service provider.
How do Regulations address the current market challenge
(general considerations)?
The Regulations provide for types of policies that will be allowed to be sold in the long-term and short-term insurance market.
In determining whether a product should be allowed to be sold, consideration was given to the current or potential harm that a health insurance policy may cause to medical schemes environment.
Balance
- The proposed conditions on health insurance products seek to ensure that the design and marketing of health insurance policies do not undermine a sustainable medical scheme industry
- But at the same time serving the needs of those who require additional protection against health related risks.
What is the CMS’s stance on Health Insurance products?
CMS Accepts
- Major medical and dread disease policies
- statement amount when disease is diagnosed
- Disability assurance products
- That have nothing to do with actual medical costs e.g. lump sum payouts, income replacement, paying outstanding debts
- Travel insurance
- health events that occur outside border of RSA for up to 180 days)
CMS Rejects
- Insurance products linked to hospital days per level of care
- Gap Cover products
- Top-up products
- Annuity linked to chronic medicines
- Annuity products that covers contributions
What is a gap cover policy?
Pay out when there is a shortfall between what a medical scheme pays a doctor for a procedure and what your doctor actually charges.
What did the Supreme Court of Appeal have to say about the definition of the business of a medical scheme?
During 2008, the Supreme Court of Appeal however found that paragraphs (a), (b) and (c) of the definition of “business of a medical scheme” in the Act should be read conjunctively [(a) AND (b) AND (c)] instead of disjunctively [(a) OR (b) OR (c)].
Therefore as it stands, the business of a medical scheme must include all three aspects as defined. If the wording included the word “or” after each subsection, it would have made it difficult for any other business to compete legally.
