UMKHANDLU WETIKIMU TETEKWELAPHA


Sihloko:	Ema-Prescribed Minimum Benefits (Tinzuzo Letincane Letimisiwe)
Sikhatsi:				1 awa
Umetfuli: 				
Luhlelo:				Setfulo silandzelwe tincingo letingenako
Lokubukiwe:			Tintfo letingu-10 lekumele utati nge-PMB


Singeniso:

I-Prescribed Minimum Benefit (i-PMB) yiphakheji levikela timo tetekwelashwa letitsite.  Lephakheji yangeniswa nguMtsetfo Wetikimu Tetekwelapha (i-Medical Schemes Act, 1998 (uMtsetfo 131 wanga-1998)), kucinisekisa kwekutsi tikimu tetekwelapha angeke tiphelelwe tinzuzo tetimo letitsite.

Sibonelo sesehlakalo (i-Case Study):
Iminyaka neminyaka dokotela waMnu X bekamuhlelela i-Coversyl Plus ngesimo sakho sedayibhethisi (i-PMB).  Kusukela nga-2007 sikimu setekwelapha saMnu sancuma kungenisa luhlu lwemitsi (formulary list), lebelingayifaki i-Coversyl Plus.  Mnu X utsi akamange sekatjelwe kusenesikhatsi kantsi watfola ngaloko ngekutsi kufunwe lenye imali ngakuye lengu-R100 ngalesikhatsi ayolandza imitsi yakhe ekupheleni kwaBhimbidvwane (Janawari) 2007.  Imitamo yekutsi avunyelwe achubeke ngemitsi yakhe, futsi isekelwa nabufakazi badokotela, yajikiswa ngulesikimu, ngako-ke Mnu X wancuma kufaka sikhalo sakhe kuMkhandlu Wetikimu Tetekwalapha (i-Council for Medical Schemes).

Ngabe iPhakheji ye-PMB imayelana ngani?

1. Ngutiphi timo letivikelwa ngaphasi kwema-PMB?
2. Ngabe lokuvikelwa kuyehluka nge-option ngayinye?
3. Tikimu tetekwelapha tineluhlu lwetimo letifana nekuhlindvwa kwebuhle (i-cosmetic surgery) lebangeke batibhadale; ngabe letimo leti tiyasebenta kuma-PMB?
4. Kunetehlakalo lapho khona lilunga litjelwa kwekutsi libhadale incenye letsite yetindleko tetimo te-PMB, ngabe loku kuvunyelwe nguMtsetfo?
5. Ngabe yini Baphakeli Betinsita Labakhetsiwe (ema-DSP)?
6. Ngabe emalunga atfola njani kutsi ngubaphi baphakeli labangema-DSP etikimu tabo?
7. Nguwaphi emalungelo netibopho letihlobene netimo letivikelwa ngema-PMB?
8. Emalunga avame kuhlangana nemagama lamakhulu lafana nabo-protocols, bo-formalaries kanye nalamanye. Kubalulekile kwati tinchazelo talamagama?
9. Uma umutsi loseluhlwini lwemitsi (formulary list) yesikimu ungasebenti ngendlela lelindzelekile nobe ubangela kuphatseka kabi, ngabe ngutiphi letinye tintfo letingentiwa ngemalunga?
10. Uma ngabe timphendvulo tadokotela netetikimu ngema-PMB tinganetisi, ngabe ukhona lokungayiwa kuye kuyewutfola lusito?


TIMPHENDVULO LETINGABA KHKONA KULEMIBUTO:

1. Ngutiphi timo letivikelwa ngaphasi kwema-PMB?
Ngekuya ngekweMtsetfo Wetikimu Tetekwelapha, tikimu tetekwelapha kumele tifake tindleko letihlobene nekuphengulwa kwesifo, kwelashwa nekunakekelwa: kwanobe ngusiphi simo setekwelashwa sesimobucayi, timo licembu lelikhawulisiwe lwetimo tetelwelashwa letingetulu kuletingu-270 kanye netimo tetifo letingapheli letingu-25.

Letinzuzo tiniketwa kakhulu etibhedlela futsi lapho khona sikimu sakho setekwelashwa sikwentele emalungiselelo ekutsi uyewulashwa. Lamalungiselelo kumele akhonjiswe kumitsetfo yesikimu.

2.	Ngabe lokuvikelwa (i-coverage) kuyehluka nge-option?
Cha. Ema-PMB tinzuzo letigunyatwe emalungelo ngaphandle kwe-option yesikimu setekwelapha labasikhetsile.

3.	Tikimu tetekwelapha tivame kuba neluhlu lwetimo letifana nekuhlindzelwa buhle (i-cosmetic surgery) labangeke batibhadale; ngabe letimo letingakavikelwa tiyasebenta kuma-PMB?
Tinzuzo Letincane Letimisiwe (i-Prescribed Minimum Benefits) timayelana nekuhlolwa, hhayi kutsi lesimo lesifike njani. Sibonelo, uma lilunga lihlindvwela buhle bese kutsi emvakwaloko lingenwe yi-septicaemia.  Nanobe uma ngabe sikimu singabhadali kuhlindzelwa buhle, kumele sibhadalele kwelashelwa i-septicaemia, ngobe simo lesivikelwa ngema-PMB.  

4.	Kunetehlakalo lapho lilunga litjelwa kwekutsi libhadale incenye letsite yetindleko tetimo te-PMB, ngabe loku kuvunyelwe nguMtsetfo?
Kutawuvunyelwa uma lilunga lincume kungasebentisi Umphakeli Wetinsita Lokhetfwe sikimu.  Lemali lenye lekhishwako ibe ngumehluko phakatsi kwetindleko mbamba kanye nalena lekumele kwekutsi ngabe ibhadalwe sikimu uma ngabe lilunga belisebentise Umphakeli Wetinsita Lokhetfwe sikimu (i-DSP), nobe liphesenti lalenye imali lekhishwa njengobe kubekiwe kumitsetfo yesikimu.

5.	Ngabe yini Baphakeli Betinsita Labakhetsiwe (ema-Designated Service Providers (ema-DSP))?
Ema-DSP baphakeli belusito lwetekwelapha nobe emacembu ebaphakeli (bodokotela, bosokhemisi, tibhedlela, emachungechunge futsi njalo njalo) laba labangakhetfwa sikimu kutsi baphakele emalunga aso ngetinsita letifana nekuhlolwa tifo, kwelashwa kanye nekunakekelelwa timo tema-PMB. 

6.	Ngabe emalunga atfola njani kutsi ngubaphi baphakeli betinsita labangema-DSP etikimu tabo?
Sikimu sinemsebenti wekwatisa emalunga aso ngemphakeli/baphakeli labakhetsiwe kantsi lomniningwane kumele uphindze kumitsetfo yesikimu.  Umkhandlu Wetikimu Tetekwalapha beweluleka tikimu kwekutsi tente tinkontileka nganobe ngubaphi baphakeli betinsita labakhetsiwe lababakhetsako, ikakhulukati tibhedlela tembuso.  Ngenca yaloko tibhedlela letinyenti tembuso tilungise emawadi lahlukile ekunakekela emalunga labo kulashwa kanye nekuhlala kwabo esibhedlela kukhokhelwa sikimu setekwelapha. 

7.	Nguwaphi emalungelo netibopho letihlobene netimo letivikelwa ngema- PMB?
Sibonelo sesibopho kutsi kumele utfole imvumo yangaphambilini nobe ujoyine luhlelo lwekuphatfwa kwetinzuzo ngaphambi kwekutsi kuvikelwa (i-cover) kwakho kucale kusebenta.  Sikimu sakho sinelilungelo lekuncuma kwekutsi nguyiphi imitsi lesitayibhadala ngasinye simo lesingapheli, yingce nje uma ngabe sisemgceni munye nemazinga ekwelapha lashicelelwe.  Futsi singabeka imikhawulo ngelinani lelivunyelwe lemitsi yetifo letingapheli.  Kodvwa, nanobe uma ungacedza lelinani, uma ngabe unesimo se-PMB sikimu sakho kusafanele kwekutsi sibhadale imitsi yesifo lengapheli lefanele loyitfola kuma-DSP aso.

8.	Emalunga avame kuhlangana nemagama lakhulu lafana nabo-'protocols', nabo-'formularies' kanye nalamanye.  Kubalulekile kwati tinchazelo talamagama
Yebo, kubalulekile kwati tinchazelo talamagama.  Emagama abo-protocols kanye nabo-Formularies asetjentiswa tikimu kuphatsa tinzuzo temalunga kanye nekunciphisa kulahlekelwa.  Sibonelo nalelinye ligama lelikhulu ngu-'treatment algorithms'.  Lawa ngemazinga lamancane ekulashwa kwawo wonkhe ema-PMB. Tikimu tetekwelapha tingaba nemitsetfo lephawula kwekutsi ngukuphi kwelashwa kanye nemitsi letitayifaka futsi nguyiphi letingeke tiyifake.  Kodvwa angeke tigucule kwelashwa kutsi kube ngaphasi kwemazinga lashicelelwe kuGazethi Yahulumende. 

9.	Uma ngabe umutsi loseluhlwini lwemitsi (formulary list) yesikimu angasebenti ngendlela lelindzelekile nobe ubangela kuphatseka kabi, ngutiphi letinye tintfo letinyentiwa ngemalunga?
Emalunga angatfula indzaba yawo kusikimu futsi angabuta ngaleminye imitsi.  Utawudzinga kwekutsi dokotela akunikete bufakazi lobudzingekile kwesekela sicelo sakho.  Sikimu ngako-ke kutawudzingakala kwekutsi sibhadale ngalokugcwele lona lomunye umuntfu.  [Buka Imitsetfotimiso Jikelele, leshicelelwe ngaphasi kwe-GN R. 1262 in GG 20556 yangamhlaka 20 Imphala (Okthoba) 1999:
"15I	Formularies (Luhlu lwemitsi)
(c)	umbandzela kumele wentiwe wekuvalwa lokufanele kwemitsi lapha umutsi loseluhlwimi (formulary) bewungasebenti kahle nobe ubangele nobe ungabangela kuphatseka kabi kumzuzi, ngaphandle kwekuhlawulisa lowo mzuzi.".]

10.	Uma ngabe timphendvulo tadokotela kanye netesikimu ngema-PMB tinganetisi, ngabe ukhona lokungayiwa kuye kutfola lusito?
Yebo, ungaya kuMkhandlu Wetikimu Tetekwelapha kute utfole lusito. Umsebenti lophambili weMkhandlu kutsi uvikele emalungelo akho kanye nekucinisekisa kwekutsi uphatfwa ngendlela lekahle.  Ungatsintsa uMkhandlu kulenombolo yelucingo 012 431 0500 nobe 0861 123 267, nobe inombolo yefeksi 012 430 7644.  Ungaphindze utfumele i-email ku support@medicalschemes.com nobe uye kuwebhusayithi yeMkhandlu ku www.medicalschemes.com.

CMS - PMBs Communication Strategy 2007 - 2008:  compiled by Phumla Khanyile

