TREATMENT GUIDELINE FOR BIPOLAR MOOD DISORDER (BMD)
	PRESCRIBED MINIMUM BENEFIT
			LEVEL 1
			LEVEL 2
	GO TO ALGORYTHM BMD MANAGEMENT		LEVEL 3
			LEVEL 4
	ACCORDING TO THE MEDICAL SCHEMES ACT, ACT 131 OF 1998, SECTION 29(O), CHAPTER 5; RULES OF MEDICAL SCHEME. MATTERS FOR WHICH RULES SHALL PROVIDE. - (1) THE REGISTRAR SHALL NOT REGISTER A MEDICAL SCHEME UNDER SECTION 24, AND NO MEDICAL SCHEME SHAAL CARRY ON ANY BUSINESS, UNLESS PROVISION IS MADE IN ITS RULES FOR THE FOLLOWING MATTERS: "THE SCOPE AND LEVEL OF MINIMUM BENEFITS THAT ARE TO BE AVAILABLE TO BENEFICIARIES AS MAY BE PRESCRIBED"
	MAJOR AFFECTIVE DISORDER, INCLUDING UNIPOLAR AND BIPOLAR DEPRESSION (AS PART OF THE DTP)		HOSPITAL-BASED MEDICAL MANAGEMENT UP TO 3 WEEKS / YEAR (INCLUDING INPATIENT ELECTRO-CONVULSIVE THERAPY AND INPATIENT PSYCHOTHERAPY) OR OUTPATIENT PSYCHOTHERAPY OF UP TO 15 CONTACTS
	BIPOLAR MOOD DISORDER (AS PART OF THE CDL)
	ACCORDING TO THE REGULATIONS TO THE MEDICAL SCHEMES ACT, ACT 131 OF 1998, REGULATIONS GNR.1262 OF 20 OCTOBER 1999; REGULATIONS; GN 1402 OF 6 OCTOBER 2003; THERAPEUTIC ALGORITHMNS FOR CHRONIC CONDITIONS; NOTICES, GN 225 OF 11 FEBRUARY 2004; REGISTERED MEDICAL SCHEMES; GN 227 OF 20 FEBRUARY 2004; FEES PAYABLE TO BROKERS, BN 73 OF 30 JUNE 2004; NOTICE OF DECLARATION OF UNDESIREBLE BUSINESS PRACTICE IN TERMS OF SECTION 61 (1) OF THE MEDICAL SCHEMES ACT, 1998 (ACT NO. 131 of 1998); REGULATIONS, GNR.1262 OF 20 OCTOBER 1999: REGULATIONS:
	CHAPTER 3 CONTRIBUTIONS AND BENEFITS:		Explanatory notes and definitions to Annexure A
	7. Definitions.—For the purposes of this chapter—		(1) Interventions shall be deemed hospital-based where they require:
			An overnight stay in hospital. or
	“designated service provider” means a health care provider or group of providers selected by the medical scheme concerned as the preferred provider or providers to provide to its members diagnosis, treatment and care in respect of one or more prescribed minimum benefit conditions;		The use of an operating theatre together with the administration of a general or regional anaesthetic. or
	“emergency medical condition” means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy;		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
	“prescribed minimum benefits” means the benefits contemplated in section 29 (1) (o) of the Act, and consist of the provision of the diagnosis, treatment and care costs of—		The use of equipment, medications or medical professionals not generally found outside hospitals.
	(a) the Diagnosis and Treatment Pairs listed in Annexure A, subject to any limitations specified in Annexure A; and		(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
	(b) any emergency medical condition;		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:
	“prescribed minimum benefit condition” means a condition contemplated in the Diagnosis and Treatment Pairs listed in Annexure A or any emergency medical condition.		(i) Tumour chemotherapy
			(ii) Tumour radiotherapy
	8. Prescribed Minimum Benefits.—		(iii) Bone marrow transplantation/rescue
			(iv) Mechanical ventilation
	(1) Subject to the provisions of this regulation, any benefit option that is offered by a medical scheme must pay in full, without co-payment or the use of deductibles, the diagnosis, treatment and care costs of the prescribed minimum benefit conditions.		(v) Hyperbaric oxygen therapy
	(2) Subject to section 29 (1) (p) of the Act, the rules of a medical scheme may, in respect of any benefit option, provide that—		(vi) Organ transplantation
	(a) the diagnosis, treatment and care costs of a prescribed minimum benefit condition will only be paid in full by the medical scheme if those services are obtained from a designated service provider in respect of that condition; and		(vii) Treatments, drugs or devices not yet registered by the relevant authority in the Republic of South Africa.
	(b) a co-payment or deductible, the quantum of which is specified in the rules of the medical scheme, may be imposed on a member if that member or his or her dependant obtains such services from a provider other than a designated service provider, provided that no co-payment or deductible is payable by a member if the service was involuntarily obtained from a provider other than a designated service provider.		(2A) In respect of treatments denoted as “medical management” or “surgical management”, note (2) above describes the standard of treatment required, namely “prevailing hospital-based medical or surgical diagnostic and treatment practice for the specified condition.” Note (2) does not restrict the setting in which the relevant care should be provided, and should not be construed as preventing the delivery of any prescribed minimum benefit on an outpatient basis or in a setting other than a hospital, where this is clinically most appropriate.
	(3) For the purposes of subregulation (2) (b), a beneficiary will be deemed to have involuntarily obtained a service from a provider other than a designated service provider, if—		(3) “Treatable” cancers.—In general, solid organ malignant tumours (excluding lymphomas) will be regarded as treatable where:
	(a) the service was not available from the designated service provider or would not be provided without unreasonable delay;		(i) they involve only the organ of origin, and have not spread to adjacent organs
	(b) immediate medical or surgical treatment for a prescribed minimum benefit condition was required under circumstances or at locations which reasonably precluded the beneficiary from obtaining such treatment from a designated service provider; or		(ii) there is no evidence of distant metastatic spread
	(c) there was no designated service provider within reasonable proximity to the beneficiary’s ordinary place of business or personal residence.		(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
	(4) Subject to subregulations (5) and (6) and to section 29 (1) (p) of the Act, these regulations must not be construed to prevent medical schemes from employing appropriate interventions aimed at improving the efficiency and effectiveness of health care provision, including such		(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.
	techniques as requirements for pre-authorisation, the application of treatment protocols, and the use of formularies.		(4) Tumour chemotherapy with or without bone marrow transplantation and other indications for bone marrow transplantation.—These 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).
	(5) When a formulary includes a drug that is clinically appropriate and effective for the treatment of a prescribed minimum benefit condition suffered by a beneficiary, and that beneficiary knowingly declines the formulary drug and opts to use another drug instead, the scheme may impose a co-payment on the relevant member.		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:
	(6) A medical scheme may not prohibit, or enter into an arrangement or contract that prohibits, the initiation of an appropriate intervention by a health care provider prior to receiving authorisation from the medical scheme or any other party, in respect of an emergency medical condition.		(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
	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.		(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 nonmalignant diseases).
	10. Personal medical savings accounts.—		(5) Solid organ transplants.—The 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) The funds in a member’s medical savings account shall not be used to pay for the costs of a prescribed minimum benefit.		(6) In certain cases, specified categories shall take precedence over others present.
	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.		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.
	(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—		(7) Hospital treatment where the diagnosis is uncertain and/or admission for diagnostic purposes.—Urgent 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.
	(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.