How (and when) to complain to the CMS

Anyone who is a member of a medical aid needs to know how (and when) to complain to the CMS. Here, we outline exactly how to do that.

What is the Council for Medical Schemes (CMS)?

The Council for Medical Schemes is a statutory body established by the Medical Schemes Act (131 of 1998) to provide regulatory supervision of private health financing through medical schemes. The Council supervises a massive and very important industry comprising more than 80 medical schemes registered in the country. Essentially, they are the regulatory body of the various medical aims (schemes) in South Africa.

How does the CMS help people with diabetes?

Diabetes is recognised as a chronic condition and is listed as one of the 26 chronic conditions for Prescribed Minimum Benefits (PMBs) by Medical Aid Schemes. PMBs are a feature of the Medical Schemes Act and outline that schemes have to cover the costs related to the diagnosis, treatment and care of diabetes. (More information here.)

If you feel that you are being unfairly treated by your Medical Aid Scheme, the Council of Medical Aid Schemes can protect you by informing you about your rights, obligations and other matters, in respect of medical schemes. The CMS will also ensure that complaints raised by members of the public are handled appropriately and speedily.

When do you need to contact the CMS?

Any person who is aggrieved with the conduct of a medical scheme can submit a complaint.

It’s important to try to resolve complaints through the complaints mechanisms in place at the respective medical scheme before approaching the Council for assistance. Find out more about the process here.

So: first complain to your medical aid if your FreeStyle Libre is declined, for example, and then go to the CMS if your medical aid refuses to listen to you.

This is why medical aids decline CGM / flash glucose monitors

1. The medical aid states in the decline that it is not a PMB level of care.
   PMB stands for Prescribed Minimum Benefits. Here’s how to respond:

• If you are a member of a private medical aid, you’re paying a premium and so should not only get the bare minimum (PMBs are an outline of what is covered in state care). Diabetes technology like the FreeStyle Libre is available on buy out at several state facilities. (Buy out is when a technology is considered on a case-by-case basis, on clinical criteria.) If you pay a premium, consideration should be given to more benefits than what is available in state.

2. There is not sufficient clinical evidence.
   Here’s how to respond:

• The FreeStyle Libre flash glucose monitor, for example, has been approved globally. Guidelines have been published around the world as far back as 2011, yet people with diabetes in South Africa still can’t access the technology, based on decisions made in contradiction to numerous international decision makers.
• Vigorous clinical assessments were done by International Health Boards and were all approved based on evidence. This includes the American board, the FDA, and European CE mark.
• International guidelines were published by various international payers and  associations, such as The National Institute for Health and Care Excellence (NICE), International Diabetes Federation (IDF), the  ATTD, EASD, ES, Australian Diabetes Society, and ISPAD.
• If they ask for specifics, here is a list of clinical data that you can share:

Clinical data

• Diabetes Technology: Standards of Medical Care in Diabetes—2019 | Diabetes Care (diabetesjournals.org)
• https://www.nice.org.uk/advice/mib110/chapter/The-technology
• idf-ispad_guidelines_2011_0.pdf (ymaws.com)
• Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) | Diabetes Care (diabetesjournals.org)
• Diabetes Technology—Continuous Subcutaneous Insulin Infusion Therapy and Continuous Glucose Monitoring in Adults: An Endocrine Society Clinical Practice Guideline | The Journal of Clinical Endocrinology & Metabolism | Oxford Academic (oup.com)
• Australian Diabetes Society – Position Statements
• http://www.diabetologists-abcd.org.uk/n3/Freestyle_Libre_Audit.htm

The step-by-step complaints process

1. To submit a manual complaint to the CMS, download the form here. 
2. Complete the form with your personal details.
3. In the form, provide a summary of the facts.
4. Attach any supporting documentation i.e. accounts, statements, doctor’s reports, broker letters etc. to substantiate your complaint.
5. Send the completed form along with your supporting documentation to The Council for Medical Schemes: Complaints Unit at complaints@medicalschemes.co.za.

You can also post your completed form and any supporting documents to:

The Council for Medical Schemes: Complaints Unit
Private Bag X34
Hatfield
0028

Find out more at www.medicalschemes.co.za/consumer-assistance/complaintsprocedure

Now you know how (and when) to complain to the CMS. If we all raise our voices together, we can create change – individually we don’t have power, but together we do!

What to read next?

What is a CGM? Flash glucose monitoring and CGM: Not sure what the difference is, or what these words mean? Read this article.

We did it! How to claim the Discovery CGM Benefit: A step-by-step guide to claiming the new CGM Benefit.

Your options on the Discovery CGM Benefit: There are 3 CGM / flash glucose monitors available in South Africa. Here’s what they are, and how much they cost.

Photo by Kelly Sikkema on Unsplash