A chronic condition is a long-lasting health issue that typically persists for three months or more. These conditions may not be cured completely but can be managed through medication, therapy, and other ongoing treatments. Common examples include diabetes, hypertension, asthma, and arthritis. Chronic conditions require continuous medical care and can significantly impact a person’s quality of life.
The legislation governing the provision of the prescribed minimum benefits (PMBs) is contained in the regulations enacted under the Medical Schemes Act, 1998 (Act No. 131 of 1998). There are a limited set of 271 medical conditions (defined in the Diagnosis Treatment Pairs) and 26 chronic conditions (defined in the Chronic Disease List).
A Diagnostic Treatment Pair (DTP) establishes a direct connection between a medical diagnosis and its corresponding course of treatment. This ensures that each one of the 271 PMB conditions has an associated treatment regimen which is grounded in evidence-based healthcare practices and considers cost-effectiveness.
The healthcare management for certain PMB conditions under a DTP can involve long-term medication, such as treatments for tuberculosis (TB), HIV/AIDS, and the management of menopausal symptoms.
The mandatory PMB funding covered for the 26 chronic diseases includes all essential medications, medical consultations, and testing that pertains to the specific condition. This may be set out in a detailed treatment plan, which outlines the full range of services and benefits that are eligible for funding once a member has registered their chronic condition.
What is a Prescribed Minimum Benefit (PMB)?
In South Africa, a Prescribed Minimum Benefit (PMB) is a set of defined benefits provided by medical aid schemes that ensure that all members have access to certain minimum health services, regardless of the benefit option they have chosen. The purpose of PMBs is to provide members with continuous care to improve their health and wellbeing and to make healthcare more affordable.
There are two primary purposes for Prescribed Minimum Benefits (PMBs):
- Continuous healthcare coverage: PMBs ensure that all members of medical schemes and their dependents continue to have healthcare coverage for PMBs throughout the year, even if their allocated benefits are exhausted.
- Mandatory coverage by law: As stipulated by the Medical Schemes Act, medical schemes are required to cover PMB conditions, even if the treatment is provided at a state hospital.
Why Are PMBs Important?
PMBs guarantee coverage for the treatment of significant health issues, which can be financially draining without insurance. This includes the management of chronic conditions, emergency medical conditions, and selected surgical procedures. PMBs ensure that all members of medical aid schemes receive essential health care for certain life-threatening and chronic conditions without worrying about the financial burden, which can lead to better overall public health outcomes.
Focus on your long-term health
Knowing that certain essential health services, especially for chronic and potentially expensive medical conditions, are covered through PMBs provides a strong incentive for people to join medical aid schemes. Here are several reasons why this is encouraging:
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- PMBs protect members against high medical costs associated with severe health conditions, ensuring treatments are more affordable and accessible.
- Members have guaranteed access to treatments for chronic and serious health conditions, which might be unaffordable without coverage.
- Having medical aid coverage that includes PMBs provides peace of mind knowing that you and your family’s health needs will be taken care of without leading to financial distress.
- Continuous and comprehensive healthcare access helps in better management of chronic diseases, reducing complications and improving quality of life.
To find out more about PMBs and what is covered by each Profmed benefit option, click here.
