What are Prescribed Minimum Benefits?
PMBs are a set of defined benefits that ensure all medical scheme members have access to certain minimum healthcare services, regardless of the benefit option they have selected.
The Medical Schemes Act stipulates that schemes must cover the costs related to the diagnosis, treatment and care of:
- any emergency medical condition
- a list of 271 PMB medical conditions (defined in the Diagnosis Treatment Pairs – DTPs), which is available on the website of the Council for Medical Schemes at www.medicalschemes.co.za
- 26 chronic conditions defined in the Chronic Disease List (CDL).
The 271 PMB conditions are not required to be registered or authorised with the Scheme. Funding for treatment and consultations is identified by the ICD-10 code that is provided by the medical practitioner on the claim.
Authorisation of Chronic conditions
Authorisation is required for the 26 chronic conditions, and the additional conditions covered by Profmed, listed per option on Profmed’s Chronic Disease List (CDL), in order to qualify for funding from the Chronic Medication benefit. Your doctor or pharmacist must authorise your chronic condition by calling Chronic Authorisations on 0800 132 345. These conditions are covered on all of Profmed’s options, but benefits will be more or less restrictive depending on the option that the member has chosen.
Chronic medication is funded from the Chronic Medication benefit, subject to available funds. The consultations, radiology and pathology related to these chronic conditions are funded from the available day-to-day benefits. Once day-to-day benefits are depleted, benefits will continue to be funded from risk, and in terms of the PMB legislation.