General Regulations, 1999

There are outstanding amendments that have not yet been applied. See the History tab for more information.

Jurisdiction

South Africa

Citation

Government Notice R1262 of 1999

Primary work

Medical Schemes Act, 1998

Date

Language

English

Type

Legislation

Download

Download PDF (526.0 KB)

Taxonomies

Subject areas > Health and Food Safety

General Regulations, 1999

Government Notice R1262 of 1999

Published in Government Gazette 20556 on 20 October 1999
There are multiple commencements

Provisions	Status
Chapter 1 (section 1); Chapter 2 (section 2–6); Chapter 5 (section 15); Chapter 6 (section 16–27); Chapter 7 (section 28); Chapter 9 (section 31–33)	commenced on 1 November 1999.
Chapter 3 (section 7–10); Chapter 4 (section 11–14); Chapter 8 (section 29–30)	commenced on 1 January 2000. Note: Annexures A and B also come into operation on this date; see section 33
Chapter 4, section 11(6), section 12(a), 12(b), 12(c), 12(d); Chapter 7, section 28(11)	commenced on 5 June 2000.

[This is the version of this document as it was from 1 March 2002 to 3 November 2002.]

[Amended by General Regulations: Amendment (Government Notice R570 of 2000) on 5 June 2000]
[Amended by General Regulations: Amendment (Government Notice R650 of 2000) on 30 June 2000]
[Amended by General Regulations: Amendment (Government Notice R247 of 2002) on 1 March 2002]

The Minister of Health has, in terms of section 67 of the Medical Schemes Act, 1998 (Act No. 131 of 1998), after consultation with the Council for Medical Schemes, made the regulations in the Schedule.

Chapter 1
Definitions

1. Definitions

In these Regulations any expression defined in the Act bears that meaning and, unless the context otherwise indicates—“broker” means a person as contemplated in section 65 of the Act whose part of regular business or part thereof provides a service or advice in respect of the introduction of prospective members to a medical scheme;“child dependant” means a dependant who is under the age of 21 or older if he or she permitted under the rules of a medical scheme to be a dependant;“creditable coverage” means any period of verifiable medical scheme membership of the applicant or his or her dependant, but excluding membership as a child dependant, terminating two years or more before the date of the latest application for membership;“enhanced option” means any benefit option which offers benefits in respect of scope of treatment and care, location of care or level of amenities available or both in addition to those required under the prescribed minimum benefits package;“hospital treatment” means any treatment which requires:(a)an overnight stay in hospital or(b)the use of an operating theatre together with the administration of a general or regional anaesthetic or(c)the application of other diagnostic or surgical procedures that carry a significant risk of death, and consequently require on-site resuscitation or surgical facilities or both; or(d)the use of equipment, medication or medical professionals not generally found at a place other than a hospital;“late joiner” means an applicant or the adult dependant of an applicant who, at the date of application for membership, is 35 years of age or older and has not been a member or a dependant of a member of any medical scheme for a period of two years immediately prior to applying for membership;“managed health care” means an arrangement through which utilisation of health care is monitored through the use of mechanisms which are designed to monitor appropriateness, promote efficacy, quality and cost effectiveness of the delivery of relevant health services;"practice code number" means the number allotted to a supplier of a relevant health service as a practice number by an organisation or body approved by the Council;“pre-existing sickness condition” means a condition for which medical advice, diagnosis, care or treatment was recommended or received within the twelve-month period ending on the date on which an application for membership was made;“public hospital system” means the entire system of hospitals of each provincial government, and includes any necessary transfer to a public hospital outside the province of residence for specialist treatment not available at the province of residence; and"the Act" means the Medical Schemes Act, 1998 (Act No. 131 of 1998).

Chapter 2
Administrative requirements

2. Registration of medical scheme

(1)Every application for registration of a medical scheme must be in writing and signed by the person applying for the registration of the medical scheme and must contain—

(a)the full name under which the proposed medical scheme is to be registered;

(b)the date on which the proposed medical scheme is to come into operation;

(c)the physical and postal addresses of the registered office of the proposed medical scheme;

(d)two copies of the rules of the proposed medical scheme, which must comply with regulation 4(1), and must be duly certified by the applicant as being true copies of the rules which will come into operation on the date of registration of the proposed medical scheme or the date of commencement of the medical scheme, whichever date is applicable;

(e)the full names, physical and postal addresses and curriculum vitae of the principal officer and trustees of the proposed medical scheme;

(f)in the case of a restricted membership medical scheme, the name or names of the participating employer(s);

(g)the name and address of the person who will administer the medical scheme;

(h)a copy of the administration agreement, in the case where the proposed medical scheme is to be administered by an administrator;

(i)a copy of any other joint-administration agreement between a medical scheme and any other party;

(j)the guarantees and the guarantee deposit vouchers as the Registrar may require;

(k)a detailed statement of services to be undertaken, directly or indirectly, on behalf of the proposed medical scheme by an administrator, broker and managed care organisation;

(l)a detailed business plan; and

(m)such other information as the Registrar may require.

(2)The application referred to in subregulation (1) must be accompanied by an application and registration fees as prescribed by regulation 31 (a) and (b).

(3)The minimum number of members required for the registration of a medical scheme established after these regulations have come into operation is 6000, and this number must be admitted within a period of three months of registration of the medical scheme.

3. Proof of membership

(1)Every medical scheme must issue to each of its members, written proof of membership containing at least the following particulars—

(a)The name of the medical scheme;

(b)the surname, first name, other initials if any, gender, and identity number of the member and his or her registered dependants;

(c)the membership number;

(d)the date on which the member becomes entitled to benefits from the medical scheme concerned;

(e)if applicable, details of waiting periods in relation to specific conditions;

(f)if applicable, the fact that the rendering of relevant health services is limited to a specific provider of service or a group or category of providers of services; and

(g)if applicable, a reference to the benefit option to which the member is admitted.

(2)A medical scheme must, within 30 days of the termination of membership or at any time at the request of any former member, or dependant, provide that member or dependant with a certificate, stating the period of cover, type of cover and whether or not the person qualified for late joiner status.

(3)A copy of the certificate contemplated in subregulation (2) must be forwarded on request to any medical scheme to which the former member or dependant subsequently applies for membership.

4. Administration of a medical scheme

(1)The rules of a medical scheme which are sent to the Registrar and any amendment thereto must comply with the following requirements:

(a)they must be printed in at least 1,5 spacing and a font of at least 12 on A4 paper of at least 80 grams;

(b)they must be printed on one side of the paper only, with a margin of at least 30 mm on the left side and at least 25 mm at the top and bottom and on the right side;

(c)headings and subheadings must be printed in bold print;

(d)no underlining must be made in the document containing the rules; and

(e)the document referred to in paragraph (d) must at the beginning contain a detailed table of contents of the rules, with references to the relevant page numbers.

(2)A medical scheme that provides more than one benefit option may not in its rules or otherwise, preclude any member from choosing, or deny any member the right to participate in, any benefit option offered by the medical scheme, provided that a member or a dependant shall have the right to participate in only one benefit option at a time.

(3)A medical scheme may in its rules provide that a member may only change to any benefit option at the beginning of the month of January each year, and by giving written notice of at least three months before such change is made.

(4)A medical scheme must not in its rules or in any other manner structure any benefit option in such a manner that creates a preferred dispensation for one or more specific groups of members or to provide for the creation of ring-fenced nett assets by means of such benefit option or to transfer accumulated pro rata net assets of such option to another medical scheme.

5. Accounts by suppliers of services

The account or statement contemplated in section 59(1) of the Act must contain the following—

(a)The surname and initials of the member;

(b)the surname, first name and other initials, if any, of the patient;

(c)the name of the medical scheme concerned;

(d)the membership number of the member;

(e)the practice code number, group practice number and individual provider registration number issued by the registering authorities for providers, if applicable, of the supplier of service and, in the case of a group practice, the name of the practitioner who provided the service;

(f)the relevant diagnostic and such other item code numbers that relate to such relevant health service;

(g)the date on which each relevant health service was rendered;

(h)the nature and cost of each relevant health service rendered, including the supply of medicine to the member concerned or to a dependant of that member; and the name, quantity and dosage of and net amount payable by the member in respect of the medicine;

(i)where a pharmacist supplies medicine according to a prescription to a member or to a dependant of a member of a medical scheme, a copy of the original prescription or a certified copy of such prescription, if the scheme requires it;

(j)where mention is made in such account or statement of the use of a theatre—

(i)the name and relevant practice number and provider number contemplated in paragraph (e) of the medical practitioner or dentist who performed the operation;

(ii)the name or names and the relevant practice number and provider number contemplated in paragraph (e) of every medical practitioner or dentist who assisted in the performance of the operation; and

(iii)all procedures carried out together with the relevant item, code number contemplated in paragraph (f); and

(k)in the case of a first account or statement in respect of orthodontic treatment or other advanced dentistry, a treatment plan indicating—

(i)the expected total amount in respect of the treatment;

(ii)the expected duration of the treatment;

(iii)the initial amount payable; and the monthly amount payable.

6. Manner of payment of benefits

(1)A medical scheme must not in its rules or in any other manner in respect of any benefit to which a member or former member of such medical scheme or a dependant of such member is entitled, limit, exclude, retain or withhold, as the case may be, any payment to such member or supplier of service as a result of the late submission or late re-submission of an account or statement, before the end of the fourth month—

(a)from the last date of the service rendered as stated on the account, statement or claim; or

(b)during which such account, statement or claim was returned for correction.

(2)If a medical scheme is of the opinion that an account, statement or claim is erroneous or unacceptable for payment, it must inform the member within 30 days after receipt of such account, statement or claim that it is erroneous or unacceptable for payment and state the reasons for such an opinion.

(3)After a member has been informed as referred to in subregulation (2), such member must be afforded an opportunity to correct and resubmit such account or statement before the end of the fourth month following the date from which it was returned for correction.

(4)If an account, statement, or claim is correct or where a corrected account, statement or claim is received, as the case may be, a medical scheme must, in addition to the payment contemplated in section 59 (2) of the Act, dispatch to the member a statement containing at least the following particulars—

(a)The name arid the membership number of the member;

(b)the name of the supplier of service;

(c)the final date of service rendered by the supplier of service on the account or statement which is covered by the payment;

(d)the total amount charged for the service concerned; and

(e)the amount of the benefit awarded for such service.

Chapter 3
Contributions and benefits

7. Contributions in respect dependants

A medical scheme may in its rules provide that contributions in respect of a child dependant may be less than those determined in respect of other dependants.

8. Prescribed minimum benefits

(1)From the date of commencement of these regulations, the prescribed minimum benefits that medical schemes must offer in terms of the Act consist of the provision of treatment for all the categories of Diagnosis and Treatment Pairs listed in Annexure A subject to any limitations specified in Annexure A.

(2)Any benefit option that is offered by a medical scheme must reimburse in full, without co-payment or the use of deductibles, the diagnostic, treatment and care costs of the prescribed minimum benefit conditions specified in Annexure A in at least one provider or provider network which must at all times include the public hospital system.

(3)Cover in the public hospital system must include all the costs of diagnosis, treatment and care for the prescribed minimum benefit Diagnosis-Treatment Pairs in Annexure A to a level and entitlement that is not different in terms of quality and intensity to the services provided to publicly funded patients.

(4)Medical schemes may offer enhanced options to their members through additional cover for any specificific entitlements: Provided that diagnosis, treatment and care under the prescribed minimum benefits is provided.

(5)The options referred to in subregulation (4) may include the use of alternative providers or provider networks and could incorporate member co-payments, or enhanced options for other benefits that fair outside of the prescribed minimum benefits or both.

(6)If cover for a prescribed minimum benefit as defined in Annexure A under an enhanced option is exhausted while the patient still requires diagnosis, care or treatment for that prescribed minimum benefit, that patient may be transferred to a lower cost provider or provider network, but the medical scheme must continue to be fully liable for all costs incurred in delivering the prescribed minimum benefit care that is required.

(7)A member or dependant shall not lose his or her entitlement to any prescribed minimum benefit, regardless of any enhanced option they may choose or as a result of any condition associated with that enhanced option.

(8)Medical schemes may employ appropriate interventions aimed at improving the efficiency and effectiveness of health care provision provided that every option offered by a medical scheme must at least provide full cover for prescribed minimum benefits in at least the public hospital system.

(9)These regulations must not be construed to prevent medical schemes from employing techniques such as the designation of preferred providers, requirements for Pre-Authorization and the application of Treatment Protocols: Provided that in the case of Pre-Authorization a medical scheme must not refuse authorization for the delivery in a public hospital of standard treatment for a prescribed minimum benefit as defined in Annexure A.

(10)Every Medical Scheme must make provision in its rules for the reimbursement of the cost of care that is considered to fall within the Prescribed Minimum Benefits prescribed under these Regulations within all the membership options that the medical scheme offers.

(11)Medical schemes must refer to these Regulations in their rules and such reference may not be a full reproduction of these Regulations.

(12)Medical schemes must specify in their rules whether they restrict the provision of the prescribed minimum benefits under specific membership options to a named network of providers.

(13)The Registrar must determine whether a medical scheme's rules are consistent with the provisions of the Act and these Regulations before approving such rules.

(14)Disputes and complaints between a member or a provider and the medical scheme in relation to minimum prescribed benefits must be dealt with in terms of Chapter 10 of the Act.

9. Limits on benefits

A medical scheme may, in respect of the financial year in which a member joins the scheme, reduce the annual benefits with the exception of the prescribed minimum benefits, pro-rata to the period of membership in the financial year concerned calculated from the date of admission to the end of the financial year concerned.

10. Personal medical savings accounts

(1)A medical scheme must not pay into a members’ personal medical savings account an amount that exceeds the equivalent of three contribution months of the total contribution made in respect of the member during the financial year concerned.

(2)The limit on contributions into personal medical savings accounts apply to each individual member of a medical scheme.

(3)Funds deposited in a member’s personal medical savings account must not be used to offset contributions.

(4)Credit balances in a member’s personal medical savings account shall be transferred to another medical scheme with a personal medical savings account regime when such member changes medical schemes.

(5)Credit balances in a member’s personal medical savings account must be taken as a cash benefit, subject to applicable laws, when the member terminates his or her membership of a medical scheme or benefit option without enrolling in another medical scheme or enrolls in another medical scheme without a personal medical savings account provision.

(6)Any balance in a members personal medical savings account shall be excluded from the calculation of the mandatory nett assets of the medical scheme.

(7)Every medical scheme must provide the following to the Registrar with regard to members’ personal medical savings accounts—

(a)details of amounts paid into members’ personal medical savings accounts;

(b)details on both debit and credit balances in members’ personal medical savings accounts;

(c)details on amounts paid to members or their estates on termination through resignation or death;

(d)details on benefits, by category, paid out of members’ personal medical savings accounts; and

(e)any other reports that the Council may specify from time to time.

Chapter 4
Waiting periods and premium penalties

11. ***

[regulation 11 amended by section 2(a) and (b) of Government Notice R650 of 2000, substituted by section 2 of Government Notice R570 of 2000 and repealed by section 2 of Government Notice R247 of 2002]

12. ***

[regulation 12 amended by section 3 of Government Notice R650 of 2000, substituted by section 3 of Government Notice R570 of 2000 and repealed by section 2 of Government Notice R247 of 2002]

13. Premium penalties for persons joining late in life

(1)A medical scheme may apply premium penalties to an applicant or dependant of a late joiner and such penalties must be applied only to the portion of the contribution related to the member or any adult dependant who qualifies for late joiner penalties.

(2)The premium penalties referred to in subregulation (1) shall not exceed the following bands:

Number of years an applicant was not a member of a medical scheme after age 30	Maximum penalty
5-9 years	1.05 x contribution
10-19 years	1.25 x contribution
20-29 years	1.5 x contribution
30+ years	1.75 x contribution

(3)Any years of creditable coverage which can be demonstrated by the applicant or his or her dependant shall be subtracted from his or her current age in determining the applicable penalty.

(4)Where an applicant or his or her dependant produces evidence of creditable coverage after a late joiner penalty has been imposed, the scheme must recalculate the penalty and apply such revised penalty from the time such evidence is provided.

(5)Late joiner penalties may continue to be applied upon transfer of the member or adult dependant to other medical schemes.

(6)Medical schemes must accept late joiners applying for membership without imposing any of the penalties prescribed in subregulation (1) for a period of 15 months from 1 January 2000 until 31 March 2001 and such applications must be accepted on a first come, first served basis.[subregulation (6) substituted by section 4 of Government Notice R570 of 2000]

(7)A medical scheme must report annually to the Registrar on the number of late joiners enrolled in each band during the previous year and cumulatively.

14. Conditions for continued membership

(1)If a medical scheme requires that continued membership referred to in section 29(1)(s) and (t) of the Act be subject to a qualifying period of membership in respect of the member, such period shall not exceed five years.

(2)In order to qualify for continued membership contemplated in subregulation (1), contributions may be paid to cover any outstanding period.

(3)Previous membership of any other medical scheme by a member must be taken into account in determining the period referred to in subregulation (1).

Chapter 5
Provision of managed health care

15. Conditions for providing managed health care

(1)If a medical scheme provides benefits to its members by means of a managed health care arrangement with another person, such arrangement—

(a)must be in writing;

(b)must be with a person who has applied to the Council for accreditation; and

(c)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)The arrangement contemplated in subregulation (1) must specifically provide that no member or dependant of a member may be held liable by the participating provider for any sums owed by the medical scheme or any other person.

(3)An arrangement between a medical scheme and a provider of a managed health care service must require either party to give at least 90 days prior notice before terminating such arrangement.

(4)A medical scheme shall not enter into any arrangement where a provider of a relevant health service is forbidden in any manner from informing patients of the care they require, including various treatment options, and whether in the provider’s view, such care is medically necessary and appropriate.

(5)A medical scheme shall not terminate an arrangement with a provider, nor shall it enter into a arrangement with any other person that provides for termination as a result of—

(a)the provider expressing disagreement with a decision to deny or limit benefits to a member;

(b)the provider assisting the member to seek reconsideration of any such decision; or

(c)a provider discussing with a member any aspect of the member’s medical condition, any proposed treatment or treatment alternatives, whether covered by the medical scheme or not;

(6)Where a medical scheme or any other person who provides a managed health care service to a medical scheme proposes to terminate an arrangement with the provider, the notice of termination must include—

(a)the reasons for the proposed termination;

(b)a notice that the provider has a right to request a hearing before an impartial panel appointed by the Council for that purpose;

(c)a period of not less than 30 days within which a provider may request a hearing; and

(d)the date for the hearing which must be within 30 days from the date of receipt of the request for a hearing.

(7)The panel contemplated in subregulation (6)(b) must decide within three days of such hearing, and must communicate the decision to the provider, and the decision may be a reinstatement of the provider, or provisional reinstatement subject to conditions determined by the panel or termination of the arrangement with the provider.

(8)A medical scheme may not use a financial incentive that directly or indirectly compensates a provider for ordering or providing services that are not necessary or appropriate to patients.

(9)Any information pertaining to the diagnosis, treatment or health of any member of a medical scheme or of any dependant of such member must be treated as confidential.

(10)A medical scheme must have access to any treatment records held by the provider and other information pertaining to the diagnosis, treatment and health status of the member in terms of the arrangement, but such information may not be disclosed by the provider to any other person without written consent of the member, unless such disclosure is in terms of any legislation.

(11)A medical scheme may not prohibit, or enter into an arrangement that prohibits the initiation of appropriate intervention by a provider prior to receiving authorization from the medical scheme or any other party, where a person suffers from a condition that requires immediate medical or surgical intervention.

(12)Any decision to deny coverage shall be made by a medical practitioner and after consultation with a medical practitioner treating the patient.

(13)A member may appeal against the decision of the review panel referred to in subregulation (6)(b) to the Council and the Council must hear the appeal as soon as it is practically possible.

Chapter 6
Administrators of medical schemes

16. Compliance with conditions by administrators

In this Chapter—"internal financial controls" means controls which are established in order to ensure a reasonable safeguarding of assets against unauthorized use or disposition, the maintenance of proper accounting records and the reliability of financial information used within the business of the administrator.

17. Conditions to be complied with by administrators

(1)A person desiring to act as an administrator of a medical scheme must apply to Council for accreditation.

(2)An application for accreditation referred to in subregulation (1) must be in writing and must contain—

(a)the full name and curriculum vitae of the person who is the head of the administrator’s business;

(b)the home and business addresses and telephone numbers of the person referred to in paragraph (a);

(c)the name of the auditor referred to in regulation 20;

(d)a report prepared by the auditor in the form set out in Annexure C, indicating whether or not the administrator's system of internal financial control is adequate for the size and complexity of the business of the medical scheme or schemes to be administered;

(e)a copy of the proposed administration agreement between the administrator and the medical scheme or schemes concerned; and

(f)such other information or document as the Council may from time to time require.

(3)Accreditation as an administrator is only valid for a period of two years.

18. Agreement in respect of administration

(1)Prior to the commencement of administrative functions with regard to a particular medical scheme, an administrator must enter into a written agreement with the relevant medical scheme in which the terms and conditions of the administration of the medical scheme are recorded.

(2)The agreement referred to in subregulation (1) must provide—

(a)for the scope and duties of the administrator;

(b)that the administrator must, on behalf of the medical scheme, administer the business of a medical scheme in accordance with the Act and as provided for in the rules of the medical scheme;

(c)for the basis on which the administrator is to be remunerated;

(d)for the termination of the agreement at the instance of either party after notice in writing of a period of not less than 90 days and hot more than 180 days; and

(e)that all registers, minute books, records and all other data pertaining to the medical scheme, must at all times remain the sole property of the medical scheme concerned.

(3)Any changes to the agreement referred to in subregulation (1) must be in writing and must be effected by way of an addendum to the existing agreement or a new agreement between the administrator and the medical scheme.

(4)If on the date of coming into operation of this Chapter, an agreement is in force in terms of which an administrator is administering a medical scheme and the existing agreement does not comply with the requirements of this Chapter, such administrator must enter into a new agreement which complies with this Chapter with every medical scheme within six months from the date of coming into operation of this Chapter, unless the medical scheme notifies the Registrar that the interests of the medical scheme are protected in terms of the existing agreement.

19. Termination of administration agreements

(1)If the administration agreement between a medical scheme and an administrator is terminated, such administrator must furnish a report to the Registrar not later than 60 days after such termination, confirming—

(a)that all documents of title relating to assets, the assets register, minute books, members’ records and other records and information pertaining to the medical scheme have been delivered to the trustees of the medical scheme or the new administrators, as the case may be;

(b)the date and address of such delivery; and

(c)the name of the trustee or person at the new administrator’s business to whom the documents referred to in paragraph (a) have been delivered.

(2)If an administrator is for any reason unable to comply fully or partially with this regulation, the report referred to in subregulation (1) must contain full particulars regarding documentation which has not been delivered, the reasons therefor as well as a plan with the dates on which compliance will take place, to enable the Registrar to approve of such further period as may be determined by him or her.

20. Appointment of auditor

An administrator must appoint an auditor who must examine the accounting records and annual financial statements of the administrator in accordance with the South African auditing standards and satisfy himself or herself that—

(a)the accounting records comply with the requirements of the Act and these regulations; and

(b)that the annual financial statements are in agreement with the accounting records and properly drawn up to fairly present the financial position, changes in equity, results of operations and cash flows of the administrator in accordance with generally accepted accounting practice and in the manner required by the Act and these regulations.

21. Indemnity and fidelity guarantee insurance

An administrator must take out and maintain professional indemnity insurance and fidelity guarantee insurance from and up to such an amount as the administrator, with the concurrence of the Registrar, may determine.

22. Maintenance of financially sound condition

An administrator must at all times maintain his or her business in a financially sound condition by—

(a)having assets which are at least sufficient to meet current liabilities;

(b)providing for liabilities; and

(c)generally conducting the business to ensure that the business is at all times in a position to meet its liabilities.

23. Depositing of medical scheme moneys

An administrator must deposit any medical scheme moneys under administration, not later than the business day following the date of receipt thereof, into a bank account opened in the name of the medical scheme concerned.

24. Safe custody of documents of title

(1)Whenever a document of title relating to assets held by a medical scheme or to be held on behalf of a medical scheme comes into possession of the administrator, the administrator must make adequate arrangements to ensure the continued safety of the assets held in safe custody.

(2)The administrator must mark the document referred to in subregulation (1) in a manner which will render it possible to establish readily that the medical scheme is the owner of such assets, and maintain a register to identify ownership of assets.

25. Annual report

Within four months after the end of the financial year of the administrator, the administrator must furnish the Registrar with—

(a)a report by the auditor of the administrator in the format set out in Annexure C; and

(b)a representation letter from the management of the administrator in the format set out in Annexure D.

26. Furnishing of other information

(1)An administrator must furnish the Registrar with such information concerning the administrator’s shareholders, directors, members, partners and senior employees as the Registrar may from time to time require.

(2)If there is a change of owners, directors, members or shareholders and such change has an effect on the control of the administrator in question, the administrator must apply for accreditation in terms of regulation 17(2).

27. Ceasing, dissolution or liquidation of business

(1)If an administrator ceases to conduct business, is dissolved, liquidated or the administrator’s accreditation has been withdrawn, the administrator's auditor must furnish a report to the Registrar confirming—

(a)that all documents of title relating to assets, the assets register, minute books, computer records, data and other records pertaining to the medical scheme under administration have been delivered to the trustees of the medical scheme or the new administrators, as the case may be;

(b)the date and address of delivery contemplated in paragraph (a); and

(c)the name of the trustee or other person at the administrator to whom the documents referred to in paragraph (a) have been delivered.

(2)If the auditor is for any reason unable to comply fully or partially with subregulation (1), the report must contain full particulars concerning the documents which have not been delivered, full reasons therefor as well as a plan with the dates on which compliance will take place to enable the Registrar to approve of such further period as may be determined by him or her.

Chapter 7
Conditions to be complied with by brokers

28. Conditions to be complied with by brokers of medical schemes

(1)A medical scheme must not compensate any person in terms of section 65 for acting as a broker unless such person—

(a)has been accredited by the Council to act as a broker or apprentice broker;

(b)has been issued with a certificate by the Council;

(c)is a fit and proper person for purposes of acting as broker or apprentice broker;

(d)enters into a prior written agreement with the medical scheme concerned, and the nature and compensation payable to such person must be fully disclosed in the financial statements of the medical scheme concerned;

(e)discloses to the prospective member the name of the medical scheme concerned and the fact that he or she is acting in terms of an agreement;

(f)discloses to the prospective member the registered contributions for the cover;

(g)discloses to the prospective member the nature of the services rendered by the broker;

(h)provides best advice and acts at all times in good faith towards the member, the prospective member and the medical scheme concerned;

(i)provides documentary proof to the member or prospective member that he or she has obtained accreditation from the Council;

(j)discloses to the member or prospective member the compensation payable to the broker, which shall not be in excess of the maximum amount as determined in terms of subregulation (2);

(k)complies with the minimum level of services provided for in the accreditation requirements;

(l)complies with the recognised educational qualifications contemplated in subregulation (8);

(m)complies with the code of ethics for appropriate behaviour provided for in the accreditation requirements; and

(n)undertakes not to receive any other incentive, reward or compensation from any other source in addition to the disclosed compensation as contemplated in subparagraph (d).

(2)A maximum amount payable in a given year in respect of the performance of services relating to the introduction of a member to a medical scheme by any number of brokers shall not exceed 3% plus value added tax (VAT) of the contributions payable in respect of members introduced by such broker during that year.

(3)Subregulation (2) must not be construed to restrict a medical scheme from applying a sliding fee scale based on the size of the group being introduced provided that the maximum amount in respect of a member introduced as specified in subregulation (2) is not exceeded.[subregulation (3) substituted by section 5(a) of Government Notice R570 of 2000]

(4)No compensation is payable unless such compensation has been indicated in the rules of the medical scheme concerned.

(5)A medical scheme must not prevent a person from applying for membership of a medical scheme for the reason that that person is not using a broker to apply for such membership.[subregulation (5) substituted by section 5(b) of Government Notice R570 of 2000]

(6)A person is disqualified from performing broker services if he or she is an unrehabilitated insolvent or has previously received a disqualifying rating as a broker or apprentice.

(7)Any person desiring to be accredited as a broker must apply in writing to the Council and the application must be accompanied by documentary proof of a recognised educational qualification and appropriate experience.[subregulation (7) substituted by section 5(c) of Government Notice R570 of 2000]

(8)A recognised educational qualification and appropriate experience, for the purposes of this regulation, means—Grade 12 education; anda minimum of two years demonstrated experience as broker or apprentice broker in health care business;

(9)Individuals not meeting the qualifications for a broker may apply to the Council for accreditation as apprentice brokers and such applications must be accompanied by documentary proof of—

(a)Grade 12 education;

(b)agreement by a fully accredited broker to supervise the applicant;

(c)current accreditation of the supervising broker; and

(d)enrolment in a course of study sponsored by an organisation recognised by the Council.

[subregulation (9) substituted by section 5(d) of Government Notice R570 of 2000]

(10)Accreditation as a broker may be granted by the Council for two years at a time, to expire at the end of the second year and certification of brokers and apprentice brokers shall be granted on an annual basis and shall expire at the end of each year.[subregulation (10) substituted by section 5(e) of Government Notice R570 of 2000]

(11)Any person who has paid a broker compensation where there has been a material misrepresentation is entitled to the full return of all the money paid.[subregulation (11) added by section 5(f) of Government Notice R570 of 2000]

Chapter 8
Accumulated funds and assets

29. Minimum accumulated funds to be maintained by a medical scheme

(1)In this Regulation “accumulated funds” means the nett asset value of the medical scheme, excluding funds set aside for specific purposes and unrealised non-distributable reserves.

(2)Subject to sub-regulations (3) and (4), a medical scheme must at any time maintain accumulated funds expressed as a percentage of gross annual contributions for the accounting period under review which may not be less than 25%.

(3)A medical scheme must maintain accumulated funds, expressed as percentage of gross annual contributions, of not less than 10% during the first year after these regulations have come into operation, 13,5% during the second year, 17,5% during the third year, and not less than 22% during the fourth year.

(4)A medical scheme that for a period of 30 days fails to comply with subregulations (1) or (3) must notify the Registrar in writing of such failure, and must provide information relating to—

(a)the nature and causes of the failure, and

(b)the course of action being adopted to ensure compliance therewith.

30. Limitation on assets to be held in the Republic

(1)A medical scheme must have assets of the kinds and categories specified in column 1 of Annexure B in the Republic, the aggregate fair value of which, on any day, is not less than the aggregate of—

(a)the aggregate fair value on that day of its liabilities; and

(b)the minimum accumulated funds to be maintained in terms of Regulation 29.

(2)The assets that a medical scheme is required in terms of subregulation (1) to have in the Republic, when expressed as a percentage of the aggregate fair value of the liabilities and the minimum accumulated funds to be maintained in terms of Regulation 29, must not exceed the percentage specified against it in column 2 of Annexure B.

(3)For the purposes of this Regulation, an asset of the kind or category specified in items 1(b), 3(b), 5, 6(b) and 7(b) of Annexure B shall be deemed to be in the Republic.

(4)In this Regulation and Annexure B—“convertible debenture" means a debenture which is convertible into equity shares of a company;“fair value” in relation to—

(i)a credit balance, deposit or margin deposit, means the amount thereof;

(ii)property, plant and equipment, means the difference between the cost and the total amount provided or written off for depreciation or reduction in value since the date of acquisition;

(iii)an asset which is listed on a licensed stock exchange, means the selling price at which it was quoted on that stock exchange on the date at which the value is calculated;

(iv)an asset which is a long-term policy, means the amount which would be payable to the policyholder upon the surrender of the policy on the date at which the value is calculated;

(v)an asset referred to as a unit trust, means the price at which the unit would have been repurchased by the unit trust management company on the date at which the value is calculated, and, in the case of a property unit trust, the market value on the date at which the value is calculated, and, if it is listed on a stock exchange, the selling price at which it was quoted on that stock exchange on the date at which the value is calculated;

(vi)a futures contract, means the mark-to-market value, as defined in the rules of SAFEX referred to in section 17 of the Financial Markets Control Act, 1989;

(vii)an option contract, means the price at which it was quoted on a stock exchange on the date at which the value is calculated;

(viii)a derivative not mentioned in paragraph (vi) or (vii), means a price calculated as determined by the Council;

(ix)any other asset or liability, means the price at which the asset could be exchanged, or the liability settled, between knowledgeable, willing parties in an arm’s length transaction, as estimated by the medical scheme;

“linked policy” means a long-term policy in relation to which the liabilities of the long-term insurer are linked liabilities as defined in the Long-term Insurance Act, 1998 (Act No. 52 of 1998);“margin” in relation to a stock exchange, means the margin as defined in regulations issued or approved by the appropriate authority of the state in which the stock exchange is situated or which is required by that stock exchange;“margin deposit” means a margin with SAFEX and a stock exchange;“margin with SAFEX" means the margin as defined in the rules of SAFEX referred to in section 17 of the Financial Markets Control Act, 1989 (Act No 55 of 1989;“property company" means a company—

(a)whose ownership of—

(i)immovable property; or

(ii)all of the shares in the company who's principal business consists of the ownership of immovable property or which exercises control over a company who's principal business consists of the ownership of immovable property; or

(iii)a linked policy, to the extent that the policy benefits thereunder are determined by reference to the value of immovable property,

constitutes in the aggregate, 50 per cent or more of the market value of its assets;

(b)which derives 50 per cent or more of its income, in the aggregate, from—

(i)investments in immovable property; or

(ii)investments in another company which derives 50 per cent or more of its income from investments in immovable property; or

(iii)a linked policy to the extent that the policy benefits thereunder are determined by reference to the value of immovable property; or

(c)which exercises control over a company referred to in paragraphs (a) or (b);

"regulated market” means a market situated, outside the Republic which is characterised by—

(a)regular operation; and

(b)the fact that regulations are issued or approved, by the appropriate authority of the State where the market is situated to determine conditions—

(i)for the operation of and access to the market; and

(ii)to be satisfied by a financial instrument in order for it to be effectively traded in the market;

"SAFEX" means the South African Futures Exchange;“securities” include bills, bonds, debentures and debenture stock, loan stock, promissory notes, annuities, negotiable certificates of deposit and other financial instruments of whatever nature; and“shares” include share stock.

(5)In this Regulation and Annexure B an instrument may not be deemed to be a derivative unless—

(a)it is based on an underlying asset of a kind set out in Annexure B or has the equivalent effect to such an instrument; and

(b)in the case of—

(i)an over-the-counter instrument, it is capable of being readily closed out and is entered into with a counter party approved by the Council subject to such conditions as it may determine;

(ii)an instrument referred to in Annexure B, it is listed; or

(iii)any other instrument, it is regularly traded on a licensed stock exchange in the Republic, or on any other financial market in the Republic approved by the Council subject to such conditions as the Council may determine.

(6)For the purposes of calculating the fair value of assets there must be disregarded—

(a)any amount of premium, excluding a premium in respect of a reinsurance policy, which is due and payable;

(b)an amount, excluding a premium in respect of a reinsurance policy, which remains unpaid after the expiry of a period of 12 months from the date on which it became due and payable;

(c)an amount representing administrative, organisational or business extension expenses incurred directly or indirectly in the carrying on of the business of a medical scheme;

(d)an amount representing a liability or a reinsurance contract in terms of which the medical scheme concerned is the policy holder; and

(e)an asset to the extent to which such asset is encumbered.

(7)If the Registrar is satisfied that the value of an asset or liability, when calculated in accordance with subregulations (4), (5) and (6) does not reflect a fair value, he or she may direct the medical scheme to appoint another person, at the cost of the medical scheme, to place a fair value on that asset or liability, or the Registrar may direct the medical scheme to calculate the value in another manner which he or she determines and which will produce a fair value for that asset or liability.

(8)A medical scheme that for a period of 30 days fails to comply with subregulations (1) and (2) must notify the Registrar in writing of such failure, providing information relating to—

(a)the nature and causes of the failure, and

(b)the course of action being adopted to ensure compliance therewith.

Chapter 9
General matters

31. Fees payable

The following fees are payable in respect of the matters as indicated—

(a)An application for registration of a medical scheme: R5000,00;

(b)the registration of a medical scheme: R1000,00;

(c)to change the name of a medical scheme: R500,00;

(d)registration of amendments, rescissions or additions to the rules of a medical scheme in terms of section 31 of the Act, per A4 page or part thereof: R50,00;

(e)inspection of documents in terms of section 41 (3) of the Act, per document: R50,00;

(f)a copy or extract made by the Registrar of or from a document referred to in section 41 (3) of the Act, per A4 page or part thereof: R20,00;

(g)application for approval as an administrator contemplated in section 58(4) of the Act: R10 000,00;

(h)application for accreditation as a broker contemplated in section 65 of the Act: R1000,00;

(i)an appeal contemplated in section 50(3) of the Act: R 2000,00.

(j)An application for accreditation to provide a managed health care service to a medical scheme: R10,000,00

32. Penalties

The penalty for every day which a failure contemplated in section 66(3) of the Act continues, is R1000,00.

33. Commencement of the regulations

These regulations, with the exception of chapters 3, 4 and 8 come into operation on 1 November 1999. Chapters 3, 4, 8, and Annexures A and B come into operation on 1 January 2000.

ME Tshabalala MsimangMinister of Health

Annexure A

Explanatory Note

The objective of specifying a set of Prescribed Minimum Benefits within these regulations is two-fold:

(i)To avoid incidents where individuals lose their medical scheme cover in the event of serious illness and the consequent risk of unfunded utilisation of public hospitals.

(ii)To encourage improved efficiency in the allocation of Private and Public health care resources.

The Department of Health recognises that there is constant change in medical practice and available medical technology. It is also aware that this form of regulation is new in South Africa. Consequently, the Department shall monitor the impact, effectiveness and appropriateness of the Prescribed Minimum Benefits provisions. A review shall be conducted at least every two years by the Department that will involve the Council for Medical Schemes, stakeholders, Provincial health departments and consumer representatives. In addition, the review will focus specifically on development of protocols for the medical management of HIV/AIDS. These reviews shall provide recommendations for the revision of the Regulations and Annexure A on the basis of:

(i)inconsistencies or flaws in the current regulations;

(ii)the cost-effectiveness of health technologies or interventions;

(iii)consistency with developments in health policy; and

(iv)the impact on medical scheme viability and its affordability to Members.

Prescribed minimum benefits

Categories (Diagnosis and Treatment Pairs) constituting the Prescribed Minimum Benefits Package under Section 29(1)(o) of the Medical Schemes Act (listed by Organ-System chapter)

Brain and nervous system

CODE: 906ADIAGNOSIS: ACUTE GENERALISED PARALYSIS, INCLUDING POLIO AND GUILLAIN-BARRETREATMENT: MEDICAL MANAGEMENT; VENTILATION AND PLASMAPHERESISCODE: 341ADIAGNOSIS: BASAL GANGLIA, EXTRA-PYRAMIDAL DISORDERS; OTHER DYSTONIAS NOSTREATMENT: INITIAL DIAGNOSIS; INITIATION OF MEDICAL MANAGEMENTCODE: 950ADIAGNOSIS: BENIGN AND MALIGNANT BRAIN TUMOURS, TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES RADIATION THERAPYCODE: 49ADIAGNOSIS: COMPOUND/DEPRESSED FRACTURES OF SKULLTREATMENT: CRANIOTOMY/CRANIECTOMYCODE: 213ADIAGNOSIS: DIFFICULTY IN BREATHING, EATING, SWALLOWING, BOWEL, OR BLADDER CONTROL DUE TO NON-PROGRESSIVE NEUROLOGICAL (INCLUDING SPINAL) CONDITION OR INJURYTREATMENT: MEDICAL AND SURGICAL MANAGEMENT; VENTILATIONCODE: 83ADIAGNOSIS: ENCEPHALOCELE; CONGENITAL HYDROCEPHALUSTREATMENT: SHUNT; SURGERYCODE: 902ADIAGNOSIS: EPILEPSY (STATUS EPILEPTICUS, INITIAL DIAGNOSIS, CANDIDATE FOR NEUROSURGERY)TREATMENT: MEDICAL MANAGEMENT; VENTILATION; NEUROSURGERYCODE: 211ADIAGNOSIS: INTRASPINAL AND INTRACRANIAL ABSCESSTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 905ADIAGNOSIS: MENINGITIS - ACUTE AND SUBACUTETREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 513ADIAGNOSIS: MYASTHENIA GRAVIS; MUSCULAR DYSTROPHY; NEURO-MYOPATHIES NOSTREATMENT: INITIAL DIAGNOSIS; INITIATION OF MEDICAL MANAGEMENT; THERAPY FOR ACUTE COMPLICATIONS AND EXACERBATIONSCODE: 510ADIAGNOSIS: PERIPHERAL NERVE INJURY WITH OPEN WOUNDTREATMENT: NEUROPLASTYCODE: 940ADIAGNOSIS: REVERSIBLE CNS ABNORMALITIES DUE TO OTHER SYSTEMIC DISEASETREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 1ADIAGNOSIS: SEVERE/MODERATE HEAD INJURY: HEMATOMA/EDEMA WITH LOSS OF CONSCIOUSNESSTREATMENT: MEDICAL AND SURGICAL MANAGEMENT; VENTILATIONCODE: 84ADIAGNOSIS: SPINA BIFIDATREATMENT: SURGICAL MANAGEMENTCODE: 941ADIAGNOSIS: SPINAL CORD COMPRESSION, ISHAEMIA OR DEGENERATIVE DISEASE NOSTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 901ADIAGNOSIS: STROKE - DUE TO HAEMORRHAGE, OR ISCHAEMIATREATMENT: MEDICAL MANAGEMENT; SURGERYCODE: 28ADIAGNOSIS: SUBARACHNOID AND INTRACRANIAL HEMORRHAGE/HEMATOMA; COMPRESSION OF BRAINTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 305ADIAGNOSIS: TETANUSTREATMENT: MEDICAL MANAGEMENT; VENTILATIONCODE: 265ADIAGNOSIS: TRANSIENT CEREBRAL ISCHEMIA; LIFE-THREATENING CEREBROVASCULAR CONDITIONS NOSTREATMENT: EVALUATION; MEDICAL MANAGEMENT; SURGERYCODE: 109ADIAGNOSIS: VERTEBRAL DISLOCATIONS/FRACTURES, OPEN OR CLOSED WITH INJURY TO SPINAL CORDTREATMENT: REPAIR/RECONSTRUCTION; MEDICAL MANAGEMENT; INPATIENT REHABILITATION UP TO 2 MONTHSCODE: 684ADIAGNOSIS: VIRAL MENINGITIS, ENCEPHALITIS, MYELITIS AND ENCEPHALOMYELITISTREATMENT: MEDICAL MANAGEMENT

Eye

CODE: 47BDIAGNOSIS: ACUTE ORBITAL CELLULITISTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 394BDIAGNOSIS: ANGLE-CLOSURE GLAUCOMATREATMENT: IRIDECTOMY; LASER SURGERY; MEDICAL AND SURGICAL MANAGEMENTCODE: 586BDIAGNOSIS: BELL'S PALSY; EXPOSURE KERATOCONJUNCTIVITISTREATMENT: TARSORRHAPHY; MEDICAL AND SURGICAL MANAGEMENTCODE: 950BDIAGNOSIS: CANCER OF EYE & ORBIT - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES RADIATION THERAPYCODE: 901BDIAGNOSIS: CATARACT; APHAKIATREATMENT: EXTRACTION OF CATARACT; LENS IMPLANTCODE: 911BDIAGNOSIS: CORNEAL ULCER; SUPERFICIAL INJURY OF EYE AND ADNEXATREATMENT: CONJUNCTIVAL FLAP; MEDICAL MANAGEMENTCODE: 405BDIAGNOSIS: GLAUCOMA ASSOCIATED WITH DISORDERS OF THE LENSTREATMENT: SURGICAL MANAGEMENTCODE: 386BDIAGNOSIS: HERPES ZOSTER & HERPES SIMPLEX WITH OPHTHALMIC COMPLICATIONSTREATMENT: MEDICAL MANAGEMENTCODE: 389BDIAGNOSIS: HYPHEMATREATMENT: REMOVAL OF BLOOD CLOT; OBSERVATIONCODE: 485BDIAGNOSIS: INFLAMMATION OF LACRIMAL PASSAGESTREATMENT: INCISION; MEDICAL MANAGEMENTCODE: 909BDIAGNOSIS: OPEN WOUND OF EYEBALL AND OTHER EYE STRUCTURESTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 407BDIAGNOSIS: PRIMARY AND OPEN ANGLE GLAUCOMA WITH FAILED MEDICAL MANAGEMENTTREATMENT: TRABECULECTOMY; OTHER SURGERYCODE:419BDIAGNOSIS: PURULENT ENDOPHTHALMITISTREATMENT: VITRECTOMYCODE: 922BDIAGNOSIS: RETAINED INTRAOCULAR FOREIGN BODYTREATMENT: SURGICAL MANAGEMENTCODE: 904BDIAGNOSIS: RETINAL DETACHMENT, TEAR AND OTHER RETINAL DISORDERSTREATMENT: VITRECTOMY; LASER TREATMENT; OTHER SURGERYCODE: 906BDIAGNOSIS: RETINAL VASCULAR OCCLUSION; CENTRAL RETINAL VEIN OCCLUSIONTREATMENT: LASER SURGERYCODE: 409BDIAGNOSIS: SYMPATHETIC UVEITIS AND DEGENERATIVE DISORDERS AND CONDITIONS OF GLOBE; SIGHT THREATENING THYROID OPTOPATHYTREATMENT: ENUCLEATION; MEDICAL MANAGEMENT; SURGERY

Ear, nose, mouth and throat

CODE: 33CDIAGNOSIS: ACUTE AND CHRONIC MASTOIDITISTREATMENT: MASTOIDECTOMY; MEDICAL MANAGEMENTCODE: 482CDIAGNOSIS: ACUTE OTITIS MEDIATREATMENT: MEDICAL AND SURGICAL MANAGEMENT, INCLUDING MYRINGOTOMYCODE: 900CDIAGNOSIS: ACUTE UPPER AIRWAY OBSTRUCTION, INCLUDING CROUP, EPIGLOTTITIS AND ACUTE LARYNGOTRACHEITISTREATMENT: MEDICAL MANAGEMENT; INTUBATION; TRACHEOSTOMYCODE: 950CDIAGNOSIS: CANCER OF ORAL CAVITY, PHARYNX, NOSE, EAR, AND LARYNX - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 241CDIAGNOSIS: CANCRUM ORISTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 38CDIAGNOSIS: CHOANAL ATRESIATREATMENT: REPAIR OF CHOANAL ATRESIACODE: 133CDIAGNOSIS: CHOLESTEATOMATREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 910CDIAGNOSIS: CHRONIC UPPER AIRWAY OBSTRUCTION, RESULTING IN COR PULMONALETREATMENT: SURGICAL AND MEDICAL MANAGEMENTCODE: 901CDIAGNOSIS: CLEFT PALATE AND/OR CLEFT LIP WITHOUT AIRWAY OBSTRUCTIONTREATMENT: REPAIRCODE: 12CDIAGNOSIS: DEEP OPEN WOUND OF NECK, INCLUDING LARYNX; FRACTURE OF LARYNX OR TRACHEA, OPENTREATMENT: MEDICAL AND SURGICAL MANAGEMENT; VENTILATIONCODE: 346CDIAGNOSIS: EPISTAXIS - NOT RESPONSIVE TO ANTERIOR PACKINGTREATMENT: CAUTERY / REPAIR / CONTROL HEMORRHAGECODE: 521CDIAGNOSIS: FOREIGN BODY IN EAR & NOSETREATMENT: REMOVAL OF FOREIGN BODY; AND MEDICAL AND SURGICAL MANAGEMENTCODE: 29CDIAGNOSIS: FOREIGN BODY IN PHARYNX, LARYNX, TRACHEA, BRONCHUS & ESOPHAGUSTREATMENT: REMOVAL OF FOREIGN BODYCODE: 339CDIAGNOSIS: FRACTURE OF FACE BONES, ORBIT, JAW; INJURY TO OPTIC AND OTHER CRANIAL NERVESTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 219CDIAGNOSIS: LEUKOPLAKIA OF ORAL MUCOSA, INCLUDING TONGUETREATMENT; INCISION/EXCISION; MEDICAL MANAGEMENTCODE: 132CDIAGNOSIS: LIFE-THREATENING DISEASES OF PHARYNX NOS, INCLUDING RETROPHARYNGEAL ABSCESSTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 457CDIAGNOSIS: OPEN WOUND OF EAR-DRUMTREATMENT: TYMPANOPLASTY; MEDICAL MANAGEMENTCODE: 240CDIAGNOSIS: PERITONSILLAR ABSCESSTREATMENT: INCISION AND DRAINAGE OF ABSCESS; TONSILLECTOMY; MEDICAL MANAGEMENTCODE: 347CDIAGNOSIS: SIALOADENITIS; ABSCESS / FISTULA OF SALIVARY GLANDSTREATMENT: SURGERYCODE: 543CDIAGNOSIS: STOMATITIS, CELLULITIS AND ABSCESS OF ORAL SOFT TISSUE; VINCENTSANGINATREATMENT: INCISION AND DRAINAGE; MEDICAL MANAGEMENT

Respiratory system

CODE: 903DDIAGNOSIS: BACTERIAL, VIRAL, FUNGAL PNEUMONIATREATMENT: MEDICAL MANAGEMENT, VENTILATIONCODE: 158DDIAGNOSIS: # RESPIRATORY FAILURE, REGARDLESS OF CAUSETREATMENT: # MEDICAL MANAGEMENT; OXYGEN; VENTILATIONCODE: 157DDIAGNOSIS: ACUTE ASTHMATIC ATTACK; PNEUMONIA DUE TO RESPIRATORY SYNCYTIAL VIRUS IN PERSONS UNDER AGE 3TREATMENT: MEDICAL MANAGEMENTCODE: 125DDIAGNOSIS: ADULT RESPIRATORY DISTRESS SYNDROME; INHALATION AND ASPIRATION PNEUMONIASTREATMENT: MEDICAL MANAGEMENT; VENTILATIONCODE: 315DDIAGNOSIS: ATELECTASIS (COLLAPSE OF LUNG)TREATMENT: MEDICAL AND SURGICAL MANAGEMENT; VENTILATIONCODE: 340DDIAGNOSIS: BENIGN NEOPLASM OF RESPIRATORY AND INTRATHORACIC ORGANSTREATMENT: BIOPSY; LOBECTOMY; MEDICAL MANAGEMENT; RADIATION THERAPYCODE: 950DDIAGNOSIS: CANCER OF LUNG, BRONCHUS, PLEURA, TRACHEA, MEDIASTINUM & OTHER RESPIRATORY ORGANS-TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 170DDIAGNOSIS: EMPYEMA AND ABSCESS OF LUNGTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 934DDIAGNOSIS: FRANK HAEMOPTYISISTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 203DDIAGNOSIS: HYPOPLASIA AND DYSPLASIA OF LUNGTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 900DDIAGNOSIS: OPEN FRACTURE OF RIBS AND STERNUM; MULTIPLE RIB FRACTURES; FLAIL CHESTTREATMENT: MEDICAL AND SURGICAL MANAGEMENT, VENTILATIONCODE: 5DDIAGNOSIS: PNEUMOTHORAX AND HAEMOTHORAXTREATMENT: TUBE THORACOSTOMY / THORACOTOMY

Heart and vasculature

CODE: 155EDIAGNOSIS: MYOCARDITIS; CARDIOMYOPATHY; TRANSPOSITION OF GREAT VESSELS; HYPOPLASTIC LEFT HEART SYNDROMETREATMENT: MEDICAL AND SURGICAL MANAGEMENT; CARDIAC TRANSPLANTCODE: 108EDIAGNOSIS: PERICARDITISTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 907EDIAGNOSIS: ACUTE AND SUBACUTE ISCHEMIC HEART DISEASE, INCLUDING MYOCARDIAL INFARCTION AND UNSTABLE ANGINATREATMENT: MEDICAL MANAGEMENT; SURGERY; PERCUTANEOUS PROCEDURESCODE: 284EDIAGNOSIS: ACUTE PULMONARY HEART DISEASE AND PULMONARY EMBOLITREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 35EDIAGNOSIS: ACUTE RHEUMATIC FEVERTREATMENT: MEDICAL MANAGEMENTCODE: 908EDIAGNOSIS: ANEURYSM OF MAJOR ARTERY OF CHEST. ABDOMEN, NECK, -UNRUPTURED OR RUPTURED NOSTREATMENT: SURGICAL MANAGEMENTCODE: 26EDIAGNOSIS: ARTERIAL EMBOLISM/THROMBOSIS: ABDOMINAL AORTA, THORACIC AORTATREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 204EDIAGNOSIS: CARDIAC FAILURE: ACUTE OR RECENT DETERIORATION OF CHRONIC CARDIAC FAILURETREATMENT: MEDICALTREATMENTCODE: 98EDIAGNOSIS: COMPLETE, CORRECTED AND OTHER TRANSPOSTION OF GREAT VESSELSTREATMENT: REPAIRCODE: 97EDIAGNOSIS: CORONARY ARTERY ANOMALYTREATMENT: ANOMALOUS CORONARY ARTERY LIGATIONCODE: 309EDIAGNOSIS: DISEASES AND DISORDERS OF AORTIC VALVE NOSTREATMENT: AORTIC VALVE REPLACEMENTCODE: 210EDIAGNOSIS: DISEASES OF ENDOCARDIUM; ENDOCARDITISTREATMENT: MEDICAL MANAGEMENTCODE: 314EDIAGNOSIS: DISEASES OF MITRAL VALVETREATMENT: VALVULOPLASTY; VALVE REPLACEMENT; MEDICAL MANAGEMENTCODE: 902EDIAGNOSIS: DISORDERS OF ARTERIES: VISCERALTREATMENT: BYPASS GRAFT; SURGICAL MANAGEMENTCODE: 18EDIAGNOSIS: DISSECTING OR RUPTURED AORTIC ANEURYSMTREATMENT: SURGICAL MANAGEMENTCODE: 915EDIAGNOSIS: GANGRENE; SEVERE ATHEROSCLEROSIS OF ARTERIES OF EXTREMITIES; DIABETES MELLITUS WITH PERIPHERAL CIRCULATORY DISEASETREATMENT: MEDICAL AND SURGICAL MANAGEMENT INCLUDING AMPUTATIONCODE: 294EDIAGNOSIS: GIANT CELL ARTERITIS, KAWASAKI DISEASE, HYPERSENSITIVITY ANGIITISTREATMENT: MEDICAL MANAGEMENTCODE: 450EDIAGNOSIS: HEREDITARY HEMORRHAGIC TELANGIECTASIATREATMENT: EXCISIONCODE:901EDIAGNOSIS: HYPERTENSION - ACUTE LIFE-THREATENING COMPLICATIONS AND MALIGNANT HYPERTENSION; RENAL ARTERY STENOSIS AND OTHER CURABLE HYPERTENSIONTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 111EDIAGNOSIS: INJURY TO MAJOR BLOOD VESSELS - TRUNK, HEAD AND NECK, AND UPPER LIMBSTREATMENT: REPAIRCODE: 19EDIAGNOSIS: INJURY TO MAJOR BLOOD VESSELS OF EXTREMITIESTREATMENT: LIGATIONCODE; 903EDIAGNOSIS: LIFE-THREATENING CARDIAC ARRHYTHMIASTREATMENT: MEDICAL AND SURGICAL MANAGEMENT, PACEMAKERS, CARDIOVERSION CODE: 900EDIAGNOSIS: LIFE-THREATENING COMPLICATIONS OF ELECTIVE CARDIAC AND MAJOR VASCULAR PROCEDURESTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 497EDIAGNOSIS: MULTIPLE VALVULAR DISEASETREATMENT: SURGICAL MANAGEMENTCODE: 355EDIAGNOSIS: OTHER ANEURYSM OF ARTERY - PERIPHERALTREATMENT: SURGICAL MANAGEMENTCODE: 905EDIAGNOSIS: OTHER CORRECTABLE CONGENITAL CARDIAC CONDITIONSTREATMENT: SURGICAL REPAIR; MEDICAL MANAGEMENTCODE: 100EDIAGNOSIS: PATENT DUCTUS ARTERIOSUS; AORTIC PULMONARY FISTULA - PERSISTENTTREATMENT: LIGATIONCODE: 209EDIAGNOSIS: PHLEBITIS & THROMBOPHLEBITIS, DEEPTREATMENT: LIGATION AND DIVISION; MEDICAL MANAGEMENTCODE: 914EDIAGNOSIS: RHEUMATIC PERICARDITIS; RHEUMATIC MYOCARDITISTREATMENT: MEDICAL MANAGEMENTCODE: 16EDIAGNOSIS: RUPTURE OF PAPILLARY MUSCLETREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 627EDIAGNOSIS: SHOCK / HYPOTENSION - LIFE THREATENINGTREATMENT: MEDICAL MANAGEMENT; VENTILATIONCODE: 99EDIAGNOSIS: TETRALOGY OF FALLOT (TOF)TREATMENT: TOTAL REPAIR TETRALOGYCODE: 93EDIAGNOSIS: VENTRICULAR SEPTAL DEFECT - PERSISTENTTREATMENT: CLOSURE

Gastro-intestinal system

CODE: 920FDIAGNOSIS: ANAL FISSURE; ANAL FISTULATREATMENT: FISSURECTOMY; FISTULECTOMY; MEDICAL MANAGEMENTCODE: 41FDIAGNOSIS: ABSCESS OF INTESTINETREATMENT: DRAIN ABSCESS; MEDICAL MANAGEMENTCODE: 489FDIAGNOSIS: ACQUIRED HYPERTROPHIC PYLORIC STENOSIS AND OTHER DISORDERS OF THE STOMACH AND DUODENUMTREATMENT: SURGICAL MANAGEMENTCODE: 254FDIAGNOSIS: ACUTE DIVERTICULITIS OF COLONTREATMENT: MEDICAL AND SURGICAL MANAGEMENT, INCLUDING COLON RESECTIONCODE: 124FDIAGNOSIS: ACUTE VASCULAR INSUFFICIENCY OF INTESTINETREATMENT: COLECTOMYCODE: 337FDIAGNOSIS: AMOEBIASIS; TYPHOIDTREATMENT: MEDICAL MANAGEMENTCODE: 264FDIAGNOSIS: ANAL AND RECTAL POLYPTREATMENT: EXCISION OF POLYPCODE: 9FDIAGNOSIS: APPENDICITISTREATMENT: APPENDECTOMYCODE: 952FDIAGNOSIS: CANCER OF RETROPERITONEUM, PERITONEUM, OMENTUM & MESENTERY - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 950FDIAGNOSIS: CANCER OF THE GIT INCLUDING OESOPHAGUS, STOMACH, BOWEL, RECTUM, ANUS - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES RADIATION THERAPYCODE: 95FDIAGNOSIS: CONGENITAL ANOMALIES OF UPPER ALIMENTARY TRACT - EXCLUDING TONGUETREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 214FDIAGNOSIS: OESOPHAGEAL STRICTURETREATMENT: DILATION; SURGERYCODE: 516FDIAGNOSIS: ESOPHAGEAL VARICESTREATMENT: MEDICAL MANAGEMENT; SURGICAL SHUNT; SCLEROTHERAPYCODE: 902FDIAGNOSIS: GASTRIC OR INTESTINAL ULCERS WITH HEMORRHAGE OR PERFORATIONTREATMENT: SURGERY; ENDOSCOPIC DIAGNOSIS; MEDICAL MANAGEMENTCODE: 901FDIAGNOSIS: GASTROENTERITIS AND COLITIS WITH LIFE-THREATENING HAEMORRHAGE OR DEHYDRATION, REGARDLESS OF CAUSETREATMENT: MEDICAL MANAGEMENTCODE: 6FDIAGNOSIS: HERNIA WITH OBSTRUCTION AND/OR GANGRENE; UNCOMPLICATED HERNIAS UNDER AGE 18TREATMENT: REPAIR; BOWEL RESECTIONCODE: 20FDIAGNOSIS: INTESTINAL OBSTRUCTION WITHOUT MENTION OF HERNIA; SYMPTOMATIC FOREIGN BODY IN STOMACH, INTESTINES, COLON & RECTUMTREATMENT: EXCISION; SURGERY; MEDICAL MANAGEMENTCODE: 232FDIAGNOSIS: PARALYTIC ILEUSTREATMENT: MEDICAL MANAGEMENTCODE: 498FDIAGNOSIS: PERITONEAL ADHESIONTREATMENT: SURGICAL MANAGEMENTCODE: 3FDIAGNOSIS: PERITONITIS, REGARDLESS OF CAUSETREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 555FDIAGNOSIS: RECTAL PROLAPSETREATMENT: PARTIAL COLECTOMYCODE: 292FDIAGNOSIS: REGIONAL ENTERITIS; IDIOPATHIC PROCTOCOLITIS - ACUTE EXACCERBATIONS AND COMPLICATIONS ONLYTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 900FDIAGNOSIS: RUPURE OF INTRA-ABDOMINAL ORGANTREATMENT: REPAIR; SPLENECTOMY; RESECTIONCODE: 507FDIAGNOSIS: THROMBOSED AND COMPLICATED HEMORRHOIDSTREATMENT: HEMORRHOIDECTOMY; INCISION

Liver, pancreas and spleen

CODE: 325GDIAGNOSIS: ACUTE NECROSIS OF LIVERTREATMENT: MEDICAL MANAGEMENTCODE: 327GDIAGNOSIS: ACUTE PANCREATITISTREATMENT: MEDICAL MANAGEMENT, AND WHERE APPROPRIATE, SURGICAL MANAGEMENTCODE: 36GDIAGNOSIS: BUDD-CHIARI SYNDROME, AND OTHER VENOUS EMBOLISM AND THROMBOSISTREATMENT: THROMBECTOMY/LIGATIONCODE:910GDIAGNOSIS: CALCULUS OF BILE DUCT WITH CHOLECYSTITISTREATMENT: MEDICAL MANAGEMENT; CHOLECYSTECTOMY; OTHER OPEN OR CLOSED SURGERYCODE: 950GDIAGNOSIS: CANCER OF LIVER, BILIARY SYSTEM AND PANCREAS - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE:255GDIAGNOSIS: CYST AND PSEUDOCYST OF PANCREASTREATMENT: DRAINAGE OF PANCREATIC CYSTCODE: 156GDIAGNOSIS: DISORDERS OF BILE DUCTTREATMENT: EXCISION; REPAIRCODE: 910GDIAGNOSIS: GALLSTONE WITH CHOLECYSTITIS AND/OR JAUNDICETREATMENT: MEDICAL MANAGEMENT; CHOLECYSTECTOMY; OTHER OPEN OR CLOSED SURGERYCODE: 743GDIAGNOSIS: HEPATORENAL SYNDROMETREATMENT: MEDICAL MANAGEMENTCODE: 27GDIAGNOSIS: LIVER ABSCESS; PANCREATIC ABSCESSTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 911GDIAGNOSIS: LIVER FAILURE; HEPATIC VASCULAR OBSTRUCTION; INBORN ERRORS OF LIVER METABOLISM; BILIARY ATRESIATREATMENT: LIVER TRANSPLANT, OTHER SURGERY MEDICAL MANAGEMENTCODE: 231GDIAGNOSIS: PORTAL VEIN THROMBOSISTREATMENT: SHUNT

Musculoskeletal system ; Trauma nos

CODE: 353HDIAGNOSIS: ABSCESS OF BURSA OR TENDONTREATMENT: INCISION AND DRAINAGECODE: 32HDIAGNOSIS: ACUTE OSTEOMYELITISTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 950HDIAGNOSIS: CANCER OF BONES - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 206HDIAGNOSIS: CHRONIC OSTEOMYELITISTREATMENT: INCISION & DRAINAGECODE: 902HDIAGNOSIS: CLOSED FRACTURES/DISLOCATIONS OF LIMB BONES / EPIPHYSES - EXCLUDING FINGERS AND TOESTREATMENT: REDUCTION/RELOCATIONCODE: 85HDIAGNOSIS: CONGENITAL DISLOCATION OF HIP; COXA VARA & VALGA; CONGENITAL CLUBFOOTTREATMENT: REPAIR/RECONSTRUCTIONCODE: 147HDIAGNOSIS: CRUSH INJURIES OF TRUNK, UPPER LIMBS, LOWER LIMB, INCLUDING BLOOD VESSELSTREATMENT: SURGICAL MANAGEMENT; VENTILATION; ACUTE RENAL DIALYSISCODE:491HDIAGNOSIS: DISLOCATIONS/FRACTURES OF VERTEBRAL COLUMN WITHOUT SPINAL CORD INJURYTREATMENT: MEDICAL MANAGEMENT; SURGICAL STABILISATIONCODE: 500HDIAGNOSIS: DISRUPTIONS OF THE ACHILLES / QUADRICEPS TENDONSTREATMENT: REPAIRCODE: 178HDIAGNOSIS: FRACTURE OF HIPTREATMENT: REDUCTION; HIP REPLACEMENTCODE; 445HDIAGNOSIS: INJURY TO INTERNAL ORGANSTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 900HDIAGNOSIS: OPEN FRACTURE/DISLOCATION OF BONES OR JOINTSTREATMENT: REDUCTION/RELOCATION; MEDICAL AND SURGICAL MANAGEMENTCODE: 34HDIAGNOSIS: PYOGENIC ARTHRITISTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 901HDIAGNOSIS: TRAUMATIC AMPUTATION OF LIMBS, HANDS, FEET, AND DIGITSTREATMENT: REPLANTATION/AMPUTATION

Skin and breast

CODE: 465JDIAGNOSIS: ACUTE LYMPHADENITISTREATMENT: INCISION AND DRAINAGE; MEDICAL MANAGEMENTCODE: 900JDIAGNOSIS: BURNS, GREATER THAN 10% OF BODY SURFACE, OR MORE THAN 5% INVOLVING HEAD, NECK, HANDS, PERINEUMTREATMENT: DEBRIDEMENT; FREE SKIN GRAFT; MEDICAL MANAGEMENTCODE: 950JDIAGNOSIS: CANCER OF BREAST - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 954JDIAGNOSIS: CANCER OF SKIN, EXCLUDING MALIGNANT MELANOMA - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 952JDIAGNOSIS: CANCER OF SOFT TISSUE, INCLUDING SARCOMAS AND MALIGNANCIES OF THE ADNEXA-TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 349JDIAGNOSIS: CELLULITIS AND ABSCESSES WITH RISK OF ORGAN OR LIMB DAMAGE OR SEPTICEMIA IF UNTREATED; NECROTISING FASCIITISTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 901JDIAGNOSIS: DISSEMINATED BULLOUS SKIN DISEASE, INCLUDING PEMPHIGUS, PEMPHIGOID, EPIDERMOLYSIS BULLOSA, EPIDERMOLYTIC HYPERKERATOSISTREATMENT: MEDICAL MANAGEMENTCODE: 951JDIAGNOSIS: LETHAL MIDLINE GRANULOMATREATMENT: MEDICAL MANAGEMENT, WHICH INCLUDES RADIATION THERAPYCODE: 953JDIAGNOSIS: MALIGNANT MELANOMA OF SKIN - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 373JDIAGNOSIS: NON-SUPERFICIAL OPEN WOUNDS - NON LIFE-THREATENINGTREATMENT: REPAIRCODE. 356JDIAGNOSIS: PYODERMA; BODY, DEEP-SEATED FUNGAL INFECTIONSTREATMENT: MEDICAL MANAGEMENTCODE: 112JDIAGNOSIS: TOXIC EPIDERMAL NECROLYSIS AND STAPHYLOCOCCAL SCALDED SKIN SYNDROME; STEVENS-JOHNSON SYNDROMETREATMENT: MEDICAL MANAGEMENT

Endocrine, metabolic and nutritional

CODE: 331KDIAGNOSIS: ACUTE THYROIDITISTREATMENT: MEDICAL MANAGEMENTCODE: 951KDIAGNOSIS: BENIGN AND MALIGNANT TUMOURS OF PITUITARY GLAND WITH/WITHOUT HYPERSECRETION SYNDROMESTREATMENT: MEDICAL AND SURGICAL MANAGEMENT; RADIATION THERAPYCODE: 30KDIAGNOSIS: BENIGN NEOPLASM OF ISLETS OF LANGERHANSTREATMENT: EXCISION OF TUMOR; MEDICAL MANAGEMENTCODE: 950KDIAGNOSIS: CANCER OF ENDOCRINE SYSTEM, EXCLUDING THYROID - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 952KDIAGNOSIS: CANCER OF THYROID - TREATABLE; CARCINOID SYNDROMETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INLCUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 61KDIAGNOSIS: CONGENITAL HYPOTHYROIDISMTREATMENT: MEDICAL MANAGEMENTCODE: 902KDIAGNOSIS: DISORDERS OF ADRENAL SECRETION NOSTREATMENT: MEDICAL MANAGEMENT; ADRENALECTOMYCODE: 447KDIAGNOSIS: DISORDERS OF PARATHYROID GLAND; BENIGN NEOPLASM OF PARATHYROID GLANDTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 904KDIAGNOSIS: HYPER AND HYPOTHYROIDISM WITH LIFE-THREATENING COMPLICATIONS OR REQUIRING SURGERYTREATMENT: MEDICAL MANAGEMENT; SURGERYCODE: 31KDIAGNOSIS: HYPOGLYCEMIC COMA; HYPERGLYCEMIA; DIABETIC KETOACIDOSISTREATMENT: MEDICAL MANAGEMENTCODE: 236KDIAGNOSIS: IRON DEFICIENCY; VITAMIN AND OTHER NUTRITIONAL DEFICIENCIES - LIFETHREATENINGTREATMENT: MEDICAL MANAGEMENTCODE: 901KDIAGNOSIS: LIFE-THREATENING CONGENITAL ABNORMALITIES OF CARBOHYDRATE, LIPID, PROTEIN AND AMINO ACID METABOLISMTREATMENT: MEDICAL MANAGEMENTCODE: 903KDIAGNOSIS: LIFE-THREATENING DISORDERS OF FLUID AND ELECTROLYTE BALANCE, NOSTREATMENT: MEDICAL MANAGEMENT

Urinary and male genital system

CODE: 354LDIAGNOSIS: ABSCESS OF PROSTATETREATMENT: TURP; DRAIN ABSCESSCODE: 904LDIAGNOSIS: ACUTE AND CHRONIC PYELONEPHRITIS; RENAL & PERINEPHRIC ABSCESSTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 903LDIAGNOSIS: ACUTE GLOMERULONEPHRITIS AND NEPHROTIC SYNDROMETREATMENT: MEDICAL MANAGEMENTCODE: 954LDIAGNOSIS: CANCER OF PENIS AND OTHER MALE GENITAL ORGAN - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 953LDIAGNOSIS: CANCER OF PROSTATE GLAND - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 950LDIAGNOSIS: CANCER OF TESTIS - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 952LDIAGNOSIS: CANCER OF URINARY SYSTEM INCLUDING KIDNEY AND BLADDER - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 906LDIAGNOSIS: CONGENITAL ANOMALIES OF URINARY SYSTEM - SYMPTOMATIC AND LIFETHREATENINGTREATMENT: NEPHRECTOMY/REPAIRCODE: 901LDIAGNOSIS: END STAGE RENAL DISEASE REGARDLESS OF CAUSETREATMENT: DIALYSIS & RENAL TRANSPLANT WHERE DEPARTMENT OF HEALTH CRITERIA ARE MET ONLY (SEE CRITERIA PUBLISHED IN GPS 004-9001)CODE: 900LDIAGNOSIS: HYPERPLASIA OF THE PROSTATE, WITH ACUTE URINARY RETENTION OR OBSTRUCTIVE RENAL FAILURETREATMENT: TRANSURETHRAL RESECTION; MEDICAL MANAGEMENTCODE: 905LDIAGNOSIS: OBSTRUCTION OF THE UROGENITAL TRACT, REGARDLESS OF CAUSETREATMENT: CATHETERIZATION; SURGERY; ENDOSCOPIC REMOVAL OF OBSTRUCTING AGENT: LITHOTRIPSYCODE: 436LDIAGNOSIS: TORSION OF TESTISTREATMENT: ORCHIDECTOMY; REPAIRCODE: 43LDIAGNOSIS: TRAUMA TO THE URINARY SYSTEM INCLUDING RUPTURED BLADDERTREATMENT: CYSTORRHAPHY; SUTURE; REPAIRCODE: 289LDIAGNOSIS: URETERAL FISTULA (INTESTINAL)TREATMENT: NEPHROSTOMYCODE: 359LDIAGNOSIS: VESICOURETERAL REFLUXTREATMENT: MEDICAL MANAGEMENT; REPLANTATION

Female reproductive system

CODE: 539MDIAGNOSIS: ABSCESSES OF BARTHOLIN'S GLAND AND VULVATREATMENT: INCISION AND DRAINAGE; MEDICAL MANAGEMENTCODE: 288MDIAGNOSIS: ACUTE PELVIC INFLAMMATORY DISEASETREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 954MDIAGNOSIS: CANCER OF CERVIX - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES RADIATION THERAPYCODE: 952MDIAGNOSIS: CANCER OF OVARY - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 950MDIAGNOSIS: CANCER OF UTERUS - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPYCODE: 953MDIAGNOSIS: CANCER OF VAGINA, VULVA AND OTHER FEMALE GENITAL ORGANS NOS - TREATABLETREATMENT: MEDICAL AND SURGICAL MANAGEMENT, WHICH INCLUDES RADIATION THERAPY AND CHEMOTHERAPYCODE: 960MDIAGNOSIS: CERVICAL AND BREAST CANCER SCREENINGTREATMENT: CERVICAL SMEARS; PERIODIC BREAST EXAMINATIONCODE: 645MDIAGNOSIS: CONGENITAL ABNORMALITIES OF THE FEMALE GENITALIATREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 266MDIAGNOSIS: DYSPLASIA OF CERVIX AND CERVICAL CARCINOMA-IN-SITU; CERVICAL CONDYLOMATATREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 53MDIAGNOSIS: ECTOPIC PREGNANCYTREATMENT: SURGERYCODE: 460MDIAGNOSIS: FISTULA INVOLVING FEMALE GENITAL TRACTTREATMENT: CLOSURE OF FISTULACODE: 951MDIAGNOSIS: HYDATIDIFORM MOLE; CHORIOCARCINOMATREATMENT: D & C; HYSTERECTOMY; CHEMOTHERAPYCODE: 902MDIAGNOSIS: INFERTILITYTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 528MDIAGNOSIS: MENOPAUSAL MANAGEMENT, ANOMALIES OF OVARIES, PRIMARY AND SECONDARY AMENORRHOEA, FEMALE SEX HORMONES ABNORMALITIES NOS, INCLUDING HIRSUTISM.TREATMENT: MEDICAL AND SURGICAL MANAGEMENT, INCLUDING HORMONE REPLACEMENT THERAPYCODE: 434MDIAGNOSIS: NON-INFLAMMATORY DISORDERS AND BENIGN NEOPLASMS OF OVARY, FALLOPIAN TUBES AND UTERUSTREATMENT: SALPINGECTOMY; OOPHORECTOMY; HYSTERECTOMY; MEDICAL AND SURGICAL MANAGEMENTCODE: 237MDIAGNOSIS: SEXUAL ABUSE, INCLUDING RAPETREATMENT: MEDICAL MANAGEMENT; PSYCHOTHERAPYCODE; 903MDIAGNOSIS: SPONTANEOUS ABORTIONTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 435MDIAGNOSIS: TORSION OF OVARYTREATMENT: OOPHORECTOMY; OVARIAN CYSTECTOMYCODE: 530MDIAGNOSIS: UTERINE PROLAPSE; CYSTOCELETREATMENT: SURGICAL REPAIRCODE: 296MDIAGNOSIS: VOLUNTARY TERMINATION OF PREGNANCYTREATMENT: INDUCED ABORTION; MEDICAL AND SURGICAL MANAGEMENT

Pregnancy and childbirth

CODE: 67NDIAGNOSIS: # LOW BIRTH WEIGHT (UNDER 1000g) WITH RESPIRATORY DIFFICULTIESTREATMENT: # MEDICAL MANAGEMENT NOT INCLUDING VENTILATIONCODE: 967NDIAGNOSIS: # LOW BIRTH WEIGHT (UNDER 2500 GRAMS & > 1000g) WITH RESPIRATORY DIFFICULTIESTREATMENT: MEDICAL MANAGEMENT, INCLUDING VENTILATION; INTENSIVE CARE THERAPYCODE: 71NDIAGNOSIS: BIRTH TRAUMA FOR BABYTREATMENT; MEDICAL MANAGEMENT; SURGERYCODE: 901NDIAGNOSIS: CONGENITAL SYSTEMIC INFECTIONS AFFECTING THE NEWBORNTREATMENT: MEDICAL MANAGEMENT, VENTILATIONCODE: 904NDIAGNOSIS: HAEMATOLOGICAL DISORDERS OF THE NEWBORNTREATMENT: MEDICAL MANAGEMENTCODE: 54NDIAGNOSIS: NECROTIZING ENTEROCOLITIS IN NEWBORNTREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 74NDIAGNOSIS: NEONATAL AND INFANT GIT ABNORMALITIES AND DISORDERS, INCLUDING MALROTATION AND ATRESIATREATMENT: MEDICAL AND SURGICAL MANAGEMENTCODE: 902NDIAGNOSIS: NEONATAL ENDOCRINE, METABLIC AND TOXIN-INDUCED CONDITIONSTREATMENT: MEDICAL MANAGEMENTCODE: 903NDIAGNOSIS: NEUROLOGICAL ABNORMALITIES IN THE NEWBORNTREATMENT: MEDICAL MANAGEMENTCODE: 52NDIAGNOSIS: PREGNANCYTREATMENT: ANTENATAL AND OBSTETRIC CARE NECESSITATING HOSPITALISATION, INCLUDING DELIVERYCODE: 56NDIAGNOSIS: RESPIRATORY CONDITIONS OF NEWBORNTREATMENT: MEDICAL MANAGEMENT; VENTILATION

Haematological, infectious and miscellaneous systemic conditions

CODE: 50SDIAGNOSIS: SYPHILIS - CONGENITAL, SECONDARY AND TERTIARYTREATMENT: MEDICAL MANAGEMENTCODE: 168SDIAGNOSIS: # HIV-ASSOCIATED DISEASE - FIRST ADMISSION OR SUBSEQUENT ADMISSIONSTREATMENT: # MEDICAL AND SURGICAL MANAGEMENT FOR OPPORTUNISTIC INFECTIONS / LOCALISED^:MALIGNANCIESCODE: 260SDIAGNOSIS: # IMMINENT DEATH REGARDLESS OF DIAGNOSISTREATMENT: # COMFORT CARE; PAIN RELIEF; HYDRATIONCODE: 113SDIAGNOSIS: ACQUIRED HAEMOLYTIC ANAEMIASTREATMENT: MEDICAL MANAGEMENTCODE: 901SDIAGNOSIS: ACUTE LEUKAEMIAS, LYMPHOMASTREATMENT: MEDICAL MANAGEMENT, WHICH INCLUDES CHEMOTHERAPY, RADIATION THERAPY, BONE MARROW TRANSPLANTATIONCODE: 277SDIAGNOSIS: ANAEROBIC INFECTIONS - LIFE THREATENINGTREATMENT: MEDICAL MANAGEMENT; HYPERBARIC OXYGENCODE: 48SDIAGNOSIS: ANAPHYLACTIC SHOCKTREATMENT: MEDICAL MANAGEMENT; VENTILATIONCODE: 900SDIAGNOSIS: APLASTIC ANEMIA; AGRANULOCYTOSIS; OTHER LIFE-THREATENING HERIDITARY IMMUNE DEFICIENCIES.TREATMENT: BONE MARROW TRANSPLANTATION; MEDICAL MANAGEMENTCODE: 197SDIAGNOSIS: BOTULISMTREATMENT: MEDICAL MANAGEMENTCODE: 338SDIAGNOSIS; CHOLERA; RAT-BITE FEVERTREATMENT: MEDICAL MANAGEMENTCODE: 196SDIAGNOSIS: CHRONIC GRANULOMATOUS DISEASETREATMENT: MEDICAL MANAGEMENT, WHICH INCLUDES RADIATION THERAPYCODE: 916SDIAGNOSIS: COAGULATION DEFECTSTREATMENT: MEDICAL MANAGEMENTCODE: 246SDIAGNOSIS: CYSTICERCOSIS; OTHER SYSTEMIC CESTODE INFECTIONTREATMENT: MEDICAL MANAGEMENTCODE: 903SDIAGNOSIS: DEEP-SEATED (EXCLUDING NAIL INFECTIONS), DISSEMINATED AND SYSTEMIC FUNGAL INFECTIONSTREATMENT: MEDICAL MANAGEMENT; SURGERYCODE: 44SDIAGNOSIS: ERYSIPELASTREATMENT: MEDICAL MANAGEMENTCODE: 179SDIAGNOSIS: HEREDITARY ANGIOEDEMA; ANGIONEUROTIC ADEMATREATMENT: MEDICAL AND SURGICAL THERAPYCODE: 174SDIAGNOSIS: HEREDITARY HAEMOLYTIC ANAEMIAS (EG. SICKLE CELL); DYSERYTHROPOIETIC ANEMIA (CONGENITAL)TREATMENT: MEDICAL MANAGEMENTCODE: 201SDIAGNOSIS: HERPETIC ENCEPHALITIS; REYE'S SYNDROMETREATMENT: MEDICAL MANAGEMENTCODE: 913SDIAGNOSIS: IMMUNE COMPROMISE NOS AND ASSOCIATED LIFE-THREATENING INFECTIONS NOSTREATMENT: MEDICAL MANAGEMENTCODE' 912SDIAGNOSIS: LEPROSY AND OTHER SYSTEMIC MYCOBACTERIAL INFECTIONS, EXCLUDING TUBERCULOSISTREATMENT: MEDICAL MANAGEMENTCODE: 336SDIAGNOSIS: LEPTOSPIROSIS; SPIROCHAETAL INFECTIONS NOSTREATMENT: MEDICAL MANAGEMENTCODE: 252SDIAGNOSIS: LIFE-THREATENING ANAEMIA NOSTREATMENT: MEDICAL MANAGEMENT; TRANSFUSIONCODE: 908SDIAGNOSIS: LIFE-THREATENING CONDITIONS DUE TO EXPOSURE TO THE ELEMENTS, INCLUDING HYPO AND HYPERTHERMIA; LIGHTNING STRIKES]TREATMENT: MEDICAL MANAGEMENTCODE: 907SDIAGNOSIS: LIFE-THREATENING RICKETTSIAL AND OTHER ARTHROPOD-BORNE DISEASESTREATMENT: MEDICAL MANAGEMENTCODE: 172SDIAGNOSIS: MALARIA; TRYPANOSOMIASIS; OTHER LIFE-THREATENING PARASITIC DISEASETREATMENT: MEDICAL MANAGEMENTCODE: 904SDIAGNOSIS: METASTATIC INFECTIONS; SEPTICEMIATREATMENT: MEDICAL MANAGEMENTCODE: 910SDIAGNOSIS: MULTIPLE MYELOMA AND CHRONIC LEUKAEMIASTREATMENT: MEDICAL MANAGEMENT; CHEMOTHERAPYCODE: 247SDIAGNOSIS: POISONING BY INGESTION, INJECTION, AND NON-MEDICINAL AGENTSTREATMENT: MEDICAL MANAGEMENTCODE: 911SDIAGNOSIS: SEXUALLY TRANSMITTED DISEASES WITH SYSTEMIC INVOLVEMENT NOT ELSWHERE SPECIFIEDTREATMENT: MEDICAL MANAGEMENTCODE: 128SDIAGNOSIS: TETANUS; ANTHRAX; WHIPPLE’S DISEASETREATMENT: MEDICAL MANAGEMENTCODE: 122SDIAGNOSIS: THALASSEMIA AND OTHER HEMOGLOBINOPATHIES - TREATABLETREATMENT: MEDICAL MANAGEMENT; BONE MARROW TRANSPLANTCODE: 316SDIAGNOSIS: TOXIC EFFECT OF GASES, FUMES, AND VAPORSTREATMENT: MEDICAL THERAPYCODE: 11SDIAGNOSIS: TUBERCULOSISTREATMENT: DIAGNOSIS AND ACUTE MEDICAL MANAGEMENT; SUCCESSFUL TRANSFER TO MAINTENANCE THERAPY IN ACCORDANCE WITH DOH GUIDELINESCODE: 937SDIAGNOSIS: TUMOUR OF INTERNAL ORGAN (EXCLUDES SKIN): UNKNOWN WHETHER BENIGN OR MALIGNANTTREATMENT: BIOPSYCODE: 15SDIAGNOSIS: WHOOPING COUGH, DIPTHERIATREATMENT: MEDICAL MANAGEMENT

Mental illness

CODE: 182TDIAGNOSIS: ABUSE OR DEPENDENCE ON PSYCHOACTIVE SUBSTANCETREATMENT: HOSPITAL-BASED MANAGEMENT UP TO 3 WEEKS/YEARCODE: 910TDIAGNOSIS: ACUTE DELUSIONAL MOOD, ANXIETY, PERSONALITY, PERCEPTION DISORDERS AND ORGANIC MENTAL DISORDER CAUSED BY DRUGS;TREATMENT: HOSPITAL-BASED MANAGEMENT UP TO 3 DAYSCODE: 901TDIAGNOSIS: ACUTE STRESS DISORDER ACCOMPANIED BY RECENT SIGNIFICANT TRAUMA, INCLUDING PHYSICAL OR SEXUAL ABUSETREATMENT: HOSPITAL ADMISSION FOR MEDICAL/PSYCHOTHERAPY UP TO 3 DAYS; COUNSELLINGCODE: 910TDIAGNOSIS: ALCOHOL WITHDRAWAL DELIRIUM; ALCOHOL INTOXICATION DELIRIUMTREATMENT: HOSPITAL BASED MANAGEMENT UP TO 3 DAYS LEADING TO REHABILITATIONCODE: 908TDIAGNOSIS: ANOREXIA NERVOSA AND BULIMIA NERVOSATREATMENT: HOSPITAL-BASED MANAGEMENT UP TO 3 WEEKS/YEARCODE: 903TDIAGNOSIS: ATTEMPTED SUICIDE, IRRESPECTIVE OF CAUSETREATMENT: HOSPITAL-BASED MANAGEMENT UP TO 3 DAYSCODE: 184TDIAGNOSIS: BRIEF REACTIVE PSYCHOSISTREATMENT: HOSPITAL-BASED MANAGEMENT UP TO 3 WEEKS/YEARCODE: 910TDIAGNOSIS: DELIRIUM: AMPHETAMINE, COCAINE, OR OTHER PSYCHOACTIVE SUBSTANCETREATMENT: HOSPITAL-BASED MANAGEMENT UP TO 3 DAYSCODE: 902TDIAGNOSIS: MAJOR AFFECTIVE DISORDERS, INCLUDING UNIPOLAR AND BIPOLAR DEPRESSIONTREATMENT: HOSPITAL-BASED MEDICAL MANAGEMENT UP TO 3 WEEKS/YEAR; ELECTRO CONVULSIVE THERAPYCODE: 907TDIAGNOSIS: SCHIZOPHRENIC AND PARANOID DELUSIONAL DISORDERSTREATMENT: HOSPITAL-BASED MEDICAL MANAGEMENT UP TO 3 WEEKS/YEARCODE: 909TDIAGNOSIS: TREATABLE DEMENTIATREATMENT: ADMISSION FOR INITIAL DIAGNOSIS; MANAGEMENT OF ACUTE PSYCHOTIC SYMPTOMS - UP TO 1 WEEK

Explanatory notes and definitions to Annexure A

1)Interventions shall be deemed hospital-based where they require:- An overnight stay in hospital.or- The use of an operating theatre together with the administration of a general or regional anaesthetic.or- The application of other diagnostic or surgical procedures that carry a significant risk of death, and consequently require on-site resuscitation and/or surgical facilities.or- The use of equipment, medications or medical professionals not generally found outside of hospitals.

2)Where the treatment component of a category in Annexure A is stated in general terms (i.e. “medical management” or "surgical management", it should be interpreted as referring to prevailing hospital-based medical or surgical diagnostic and treatment practice for the specified condition. Where significant differences exist between Public and Private sector practices, the interpretation of the Prescribed Minimum Benefits should follow the predominant Public Hospital practice, as outlined in the relevant provincial or national public hospital clinical protocols, where these exist. Where clinical protocols do not exist, disputes should be settled by consultation with provincial health authorities to ascertain prevailing practice. The following interventions shall however be excluded from the generic medical / surgical management categories unless otherwise specified:

i)Tumour chemotherapy

ii)Tumour radiotherapy

iii)Bone marrow transplantation / rescue

iv)Mechanical ventilation

v)Hyperbaric oxygen therapy

vi)Organ transplantation

vii)Treatments, drugs or devices not yet registered by the relevant authority in the Republic of South Africa

3)“Treatable" cancers. In general, solid organ malignant tumours (excluding lymphomas) will be regarded as treatable where:

i)they involve only the organ of origin, and have not spread to adjacent organs

ii)there is no evidence of distant metastatic spread

iii)they have not, by means of compression, infarction, or other means, brought about irreversible and irreparable damage to the organ within which they originated (for example brain stem compression caused by a cerebral tumour) or another vital organ

iv)or, if points i. to iii. do not apply, there is a well demonstrated five year survival rate of greater than 10% for the given therapy for the condition concerned

4)Tumour chemotherapy with or without bone marrow transplantation and other indications for bone marrow transplantationThese are included in the prescribed minimum benefits package only where Annexure A explicitly mentions such interventions. Management may include a first full course of chemotherapy (including, if indicated, induction, consolidation and myeloablative components). Where specified in terms of Annexure A, this may be followed by bone marrow transplantation/rescue, according to tumour type and prevailing practice. The following conditions would also apply to the bone marrow transplantation component of the prescribed minimum benefits:

i)the patient should be under 60 years of age

ii)allogeneic bone marrow transplantation should only be considered where there is an HLA matched family donor

iii)the patient should not have relapsed after a previous full course of chemotherapy

iv)(points i. and ii. shall also apply to bone marrow transplantation for non-malignant diseases)

5)Solid organ transplantsThe prescribed minimum benefits Annexure includes solid organ transplants (liver, kidney and heart) only where these are provided by Public hospitals in accordance with Public sector protocols and subject to public sector waiting lists.

6)In certain cases, specified categories shall take precedence over others present. Such “overriding" categories are preceded by the sign "#" in their descriptions within Annexure A. For Example, where someone is suffering from pneumonia and HIV, because the HIV category (168S) is an overriding category, the entitlements guaranteed by the 'pneumonia' category (903D) are overridden.

7)Hospital treatment where the diagnosis is uncertain and/or admission for diagnostic purposesUrgent admission may be required where a diagnosis has not yet been made. Certain categories of prescribed minimum benefits are described in terms of presenting symptoms, rather than diagnosis, and in these cases, inclusion within the prescribed minimum benefits may be assumed without a definitive diagnosis. In other cases, clinical evidence should be regarded as sufficient where this suggests the existence of a diagnosis that is included within the package. Medical schemes may, however, require confirmatory evidence of this diagnosis within a reasonable period of time, and where they consistently encounter difficulties with particular providers or provider networks, such problems should be brought to the attention of the Council for Medical Schemes for resolution.

8)NOS - not otherwise specified

Annexure B

Limitation on assets to be held in the Republic

Item			Categories or kinds of assets	Maximum percentage of aggregate fair value of total assets of scheme
1.	(a) Inside the Republic—
	Deposits and balances in current and savings accounts with a bank or a mutual bank, including negotiable deposits, and money market instruments in terms of which such a bank or mutual bank is liable. Paid-up shares of a mutual bank, or deposits and savings accounts with the Post Office savings bank, as well as margin deposits with SAFEX:			100%
	Per bank			20%
	Per mutual bank			20%
	Post Office Savings Bank			20%
	SAFEX			5%
	Territories outside the Republic			15%
	Deposits and balances in current and savings accounts with a bank including negotiable deposits and money market instruments in terms of which such a bank is liable			2.5%
Krugerrands
1.	Bills, bonds and securities issued or guaranteed by and loans to or guaranteed by—
	(a) Inside the Republic—
		(i) A local authority authorised by law to levy rates upon immovable property		100%
		—per local authority		20%
		(ii) Development Boards established under the Black communities Development Act, 1984 (Act No. 4 of 1984)		20%
		(iii) Rand Water Board		20%
		(iv) Eskom		20%
		(v) Land and Agricultural Bank of South Africa		20%
		(vi) Local Authorities Loans Fund Board		20%
		(vii) SA Transport Services		20%
	(a) Territories outside the Republic—
	the foreign Government concerned			15%
1.	Bills, bonds and securities issued by and loans to an institution in the Republic, which bills, bonds, securities and loans the Council approved in terms of section 19(1)(h) of the Act before the deletion of that section by section 8(a) of the Act No. 53 of 1989, and also bills, bonds and securities issued by and loans to an institution in the Republic, which institution the Council likewise approved before such deletion			100%
1.	—per institution			20%
2.	Bills, bonds and securities issued by the government of or by a local authority in a territory other than the Republic, which territory the Council approved in terms of section 19(1)(I) of the Act before the deletion of that section by section 8(a) of Act No. 53 of 1989, and also bills, bonds and securities issued by an institution in such an approved territory, which institution the Council likewise approved before such deletion			100%
2.	—per authority			20%
3.	immovable property and claims secured by mortgage bonds thereon. Units in unit trust schemes in property shares and shares in, loans to and debentures, both convertible and non-convertible, of property companies			20%
	(a) inside the Republic			20%
	—per single property, property company or property development project			5%
	(b) territories outside the Republic			10%
	—per single property, property company or property development project			5%
1.	Preference and ordinary shares in companies excluding shares in property companies. ertible debentures, whether voluntarily or compulsorily convertible and units in equity unit trust mes which objective is to invest their assets mainly in shares			75%
	These investments are subject to the following limitations:
	(a) inside the Republic			75%
		(i) Unlisted shares, unlisted convertible debentures and shares and convertible debentures listed in the Development Capital sector of the Johannesburg Stock Exchange		5%
		(ii) Shares and convertible debentures listed on the Johannesburg Stock Exchange other than the Development Capital sector		75%
			(a) Per one company with a market capitalisation of R2 000 million or less	10%
			(b) per one company with a market capitalisation of more than R2 000 million	15%
	(a) territories outside the Republic—
	Preference and ordinary shares in companies, convertible debentures, whether voluntarily or compulsorily convertible			15%
		(i) unlisted shares and unlisted convertible debentures		2.5%
		(ii) shares and convertible debentures listed on any recognised foreign exchange
			(a) per one company with a market capitalisation of R2 000 million or less	15%
			(b) per one company with a market capitalisation of more than R2 000 million	10%
1.	Listed and unlisted debentures, units in a unit trust scheme with the objective to invest e generating securities and inside the Republic any secured claims against an insurance any in terms of a long-term policy of insurance			10%
1.	Computer equipment, furniture and other office equipment, as well as motor vehicles, ct to the following limitation:
		(a) Computer equipment		5% (10% by exemption)
		(b) Other equipment, as well as motor vehicles		2,5% (5% by exemption)

(b)Annexure C

Report of the independent auditors of ________________ (name of administrator) to the Registrar of Medical Schemes in compliance with Regulation 25 under the Medical Schemes Act, 1998

1.We have reviewed the [proposed] system of internal financial control of ________ (name of administrator)/[that ________ (name of administrator) intends to Implement from ________].

2.The [implementation and] maintenance of an adequate system of internal financial control [are] is the responsibility of the directors/partners/sole proprietor. Our responsibility is to report on whether or not, based on our review, anything has come to our attention that would indicate that the [proposed] system of internal financial control is not adequate for the size and complexity of the business of the medical scheme or medical schemes [to be] administered.

3.ScopeWe conducted our review in accordance with the statement of South African Auditing Standards applicable to review engagements. This standard requires that we plan and perform the review to obtain moderate assurance with regard to the [proposed] system of internal financial control. A review is limited primarily to inquiries of personnel of the administrator, inspection of evidence and observation of, and enquiry about, the operation of the internal control procedures for a small number of transactions. [A review is limited primarily to inquiries of personnel of the administrator about the proposed operation of the system of internal financial control and inspection of related evidence.]

4.Inherent limitationsBecause of the inherent limitations of a system of internal financial control, including concealment through collusion or forgery, it is possible that errors and irregularities may occur and not be detected.A review is not designed to detect all weaknesses in the system of internal financial control as it is not performed continuously throughout the period and the tests performed are on a sample basis. [A review is not designed to detect all weaknesses in the proposed system of internal financial control.][As the proposed system of internal financial control has not yet been implemented, we do not provide any assurance as to whether or not the system will operate adequately.]

5.Any projections of the evaluation of the system of internal financial control to future periods is subject to the risk that the controls may become inadequate because of changes in conditions, or that the degree of compliance with them may deteriorate.

6.Also, a review does not provide all the evidence that would be required in an audit, thus the level of assurance provided is less than given in an audit We have not performed an audit and, accordingly, we do not express an audit opinion.

7.(b) Review opinionBased on our review, nothing of significance has come to our attention that causes us to believe that the [proposed] system of internal financial control is not adequate for the size and complexity of the business of the medical scheme or schemes [to be] administered.

Name ________________Registered Accountants and Auditors ________________Chartered Accountants (SA) ________________Date ____________Address ____________Note: In the case of a new administrator, i.e. where the system of internal financial control has not yet been implemented by the administrator, the text in the square brackets should be included in the report.

Report of the independent auditors of ________________ (name of administrator) to the Registrar of Medical Schemes in compliance with Regulation 25 under the Medical Schemes Act, 1998

A. Annual financial statements

1.We have audited the attached annual financial statements of ________________ (name of administrator) (“the administrator”) set out on pages ________________ to ________________ for the year ended ______ The annual financial statements are the responsibility of the directors/partners/sole proprietor. Our responsibility is to express an opinion on these financial statements based on our audit.

2.ScopeWe conducted our audit in accordance with statements of south african auditing Standards. Those standards require that we plan and perform the audit to obtain reasonable assurance that the annual financial statements are free of material misstatement. An audit includes:

2.1examining, on a test basis, evidence supporting the amounts and disclosures in the financial statements;

2.2assessing the accounting principles used and significant estimates made by management; and

2.3evaluating the overall financial statement presentation.

We believe that our audit provides a reasonable basis for our opinion.

3.Audit opinionIn our opinion the annual financial statements fairly present, in all material respects, the financial position of the administrator at ____________ and the results of its operations and cash flows for the year then ended in accordance with generally accepted accounting practice and in the manner required by the Companies Act, 1973 (include where appropriate).

B. Consideration of the system of internal financial controls

4.in planning and performing the above-mentioned audit, we considered the system of internal financial control of the administrator in order to determine our audit procedures for the purpose of expressing our audit opinion on the annual financial statements, not to provide assurance on the system of the internal financial control.

5.The directors/partners/sole proprietor of ____________ (name of the administrator) are/is responsible for establishing and maintaining an effective system of internal financial control. In fulfilling this responsibility, estimates and judgements by the directors/partners/sole proprietor are required to assess the expected benefits and related costs of internal financial control policies and procedures. Two of the objectives of a system of internal financial control are to provide the directors/partners/sole proprietor with reasonable, but not absolute, assurance that assets are safeguarded against loss from unauthorised use or disposition and that transactions are executed in accordance with their/his/her authorisation and recorded properly to permit preparation of annual financial statements in conformity with generally accepted accounting practice.

6.Because of the inherent limitations of a system of internal financial control, it is possible that errors or irregularities may occur and not be detected. Furthermore, any projection of the evaluation of a system of internal financial control to future periods is subject to the risk that the procedures may become inadequate because of changes in circumstances, or that the degree of compliance with them may deteriorate.

7.Our consideration of the system of internal financial control would not necessarily disclose all matters in the system that might be material weaknesses. A material weakness is a condition in which the design or operation of the specific internal financial control does not reduce to a relatively low level the risk that errors or irregularities in amounts that would be material in relation to the annual financial statements being audited, may occur and not be detected within a timely period by employees in the normal performance of their assigned functions.

8.However, based on our consideration of the system of internal financial control for purposes of our audit, nothing of significance has come to our attention that causes us to believe that the financial record keeping and the system of internal financial control are not adequate for the size and complexity of the business the administrator is presently conducting. All changes to the system of internal financial control that came to our attention during the course of our audit have been recorded in writing.

9.This report is intended solely for the use of the Registrar of Medical Schemes and is not to be distributed to other parties.

Name ________________Registered Accountants and Auditors ________________Chartered Accountants (SA) ________________Date ________Address ________Note: In the case of a sole proprietor, reference to “administrator” should be read as reference to the administration business of the sole proprietor.

Annexure D (For completion on letterhead of Administrator)

Management representation letter to the Registrar of Medical Schemes in compliance with Regulation 25 under the Medical Schemes Act, 1998

This representation letter is provided in connection with the financial statements of ________ (name of the administrator) for the year ended ________ (date) to enable the Registrar to evaluate whether or not ________ (name of the administrator) has complied with the Medical Schemes Act and related regulations.We confirm, to the best of our knowledge and belief, the following representations:

1.We had ________ (quantity) registered funds under our administration at the year-end.

2.The fidelity guarantee and professional indemnity insurance cover is adequate to cover the risks of losses due to fraud, dishonesty and negligence.

3.We deposited the moneys of the medical schemes under our administration in the bank accounts of the schemes on no later than the business day following the receipt of the schemes' moneys.

4.No changes in ownership, directors, members or shareholders having the effect of a de facto change of control took place during the year ended ____________ (date), without the approval of the Registrar.

5.Administration agreements entered into with medical schemes during the year ended ________ are in writing and conform to regulation 18.

6.The following administration agreements were terminated during the year ended ________ (date) and in respect of them, regulation 19 have been complied with:

7.For the year ended ____________, we have maintained a register of documents of title in our safe custody as contemplated in regulation 24. Furthermore, all these assets are held in the names of the respective medical schemes.

8.We conducted the business in terms of the Act, the regulations, the agreements with medical schemes and the rules of these medical schemes.

9.The administration business is maintained in a financially sound condition as contemplated in regulation 22.

10.The system of internal control is adequate for the size and complexity of the business.

11.We believe that the business will continue in operational existence for the foreseeable future.

________________Managing Director________________Financial Director

▲ To the top