Social Security

•McLeod H., Matisonn S., Fourie I., Grobler P., Mynhardt S. and Marx G., (2004) The Determination of the Formula for the Risk Equalisation Fund in South Africa. Prepared for the Risk Equalisation Fund Task Group on behalf of the Formula Consultative Task Team, January 2004. [download 1.03Mb]

•For technical information see Sections 8 and 9. Appendices N, O and Q.

•Armstrong J., Deeble J., Dror D.M., Rice N., Thiede M., Van de Ven W.P.M.M. (2004) The International Review Panel Report to the South African Risk Equalization Fund Task Group. 16 February 2004. [515k]

•RETAP (2005) Methodology for the Determination of the Risk Equalisation Fund Contribution Table [Base 2002, Use 2005]. Recommendations by the Risk Equalisation Technical Advisory Panel to the Council for Medical Schemes. Recommendations Report No. 1 of 2005. 10 February 2005. Available on http://www.medicalschemes.com

•RETAP (2006) Methodology for the Determination of the Risk Equalisation Fund Contribution Table 2006 [Base 2002, Use 2006]. Recommendations by the Risk Equalisation Technical Advisory Panel to the Council for Medical Schemes. Recommendations Report No. 7. Adopted at RETAP Meeting 26 January 2006. Available on http://www.medicalschemes.com

•RETAP (2007) Methodology for the Determination of the Risk Equalisation Fund Contribution Table 2007 [Base 2005, Use 2007]. Recommendations by the Risk Equalisation Technical Advisory Panel to the Council for Medical Schemes. Recommendations Report No. 9. 17 April 2007. [949k]

From 2008 onwards, the REF Contribution Table has been called the REF Weighting Table. The tables are now developed by the Council for Medical Schemes.

Available on http://www.medicalschemes.com

•Council for Medical Schemes (2008). Methodology to determine the REF weighting table and REF count table for 2008 [Base 2005, Use 2008]. 21 April 2008

 •Council for Medical Schemes(2008). Methodology to determine the REF weighting table and REF count table for 2009 [Base 2005, Use 2009]. 30 October 2008

Successful implementation of the Risk Equalisation Fund is considered to be contingent on the accurate identification of beneficiaries with specified risk factors. Initial work by RETAP on disease definitions was expanded by a clinical team drawn from industry and the Council for Medical Schemes. This resulted in a comprehensive manual of Verification Criteria that is now in its fourth iteration.The Entry and Verification Criteria define uniform criteria that must be met by all funds in the identification of beneficiaries with the REF risk factors.

The Verification Criteria have been developed with the emphasis on the verifiability of cases and are used to ensure that gaming of the REF is identified and addressed. There are two elements to the criteria:

•the diagnosis of a particular disease, which includes specification of applicable ICD-10 codes and limitations on the practitioners that may diagnose certain complex conditions. There may also be certain mandatory tests needed to differentiate between diseases and these test results must be retained by the fund; and

•a proof of treatment element which is based on paid claims data. Initially this was based on payment date information but was changed to service date information which is less open to manipulation. Data for at least two of the three calendar months prior to the month of submission is typically required in order to demonstrate proof of treatment (see Appendix D for an example). The applicable medicines that can be used as proof are classified using the Anatomical Therapeutic Chemical (ATC) classification.

An updated version of the ATC Index is issued annually by the WHO Collaborating Centre for Drug Statistics.

The REF Entry and Verification Criteria are typically published with validity for one calendar year and made avialble on the web-site of the Council for Medical Schemes. The table below shows the versions issued and the period of validity.