Chief Directorate: Healthcare Benefits and Provider Payment Design


Accredited healthcare providers will provide care to users in what the Bill terms ‘benefits’. The Bill states that the Fund will progressively add benefits that the Fund will pay the accredited providers to provide to users.

The Bill describes two broad approaches to the benefits and how the Fund will pay providers; 1) primary health care through allocations to a group of providers/ practitioners working in a small geographical area called a ‘Contracting Unit for PHC’ or CUP, and 2) the Fund will pay providers for hospital care outcomes (no more ‘fee-for-service’) based on fixed prices for different complexity of specified and defined ‘benefits’ (such as Diagnostic Related Group benefits).

There is a need for detailed regulations to provide both users and providers with clear information on what the Fund will pay for, and how much it will pay. There will also be a need to describe how invoicing happens, when, and what the terms of payments will be, plus the details for the contract referred to in the User and Service Provider section. The standard operating procedures need to be designed, tested, and implemented, starting with PHC since the decision is to phase the implementation in sequentially over time. The plan is to start with a small number of ‘proof-of-concept’, integrated CUPs in 2022/23.