Every medical aid member has access to Prescribed Minimum Benefits (PMBs), but many people don’t understand what PMBs are, why they are so important, or how to use them.
Prescribed Minimum Benefits (PMBs) are a predefined list of benefits outlined in the Medical Schemes Act, 1998 (Act No. 131 of 1998).
The aim of PMBs is to ensure people have access to quality and continuous healthcare to improve their well-being. This also makes healthcare more affordable. Through the PMB list, all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. This means that whether you have chosen an affordable hospital plan or a comprehensive benefit option, you have access to PMBs. It also means that there are no exclusions when it comes to PMBs. For example, aesthetic surgeries generally have exclusions, but if you contract septicaemia after aesthetic surgery, your scheme would be required to review healthcare cover for the septicaemia because it may be related to PMBs. Where appropriate, additional clinical information may be used to verify if a claim qualifies as a PMB benefit.
A diagnosis approach to PMBs
One of the important specifications of PMBs is that the symptom is more important than the factors contributing to the symptom. If a doctor’s diagnosis falls into the list of 271 medical conditions or 26 chronic conditions, the causes that led to the symptoms are irrelevant – the only important factor is that you receive the appropriate treatment and care for the condition.
Why do we have PMBs?
According to the Medical Schemes Act, medical schemes must cover the costs related to the diagnosis, care and treatment of:
- Any emergency medical condition
- A limited set of 271 medical conditions (defined in the Diagnosis Treatment Pairs)
- 26 chronic conditions (defined in the Chronic Disease List)
There are two main reasons for PMBs:
- To ensure that all medical scheme members and their beneficiaries have continuous healthcare cover for PMBs, even if their benefits have been depleted for the year.
- According to the Medical Schemes Act, PMB conditions must be covered by the medical scheme, even if treatment takes place at a state hospital.
However, there are other reasons why PMBs support South Africa’s health care needs. First, they ensure that everyone who needs it has access to minimum healthcare, regardless of their state of health, age, or the medical scheme cover option they belong to. PMBs also play an important role in making sure that medical schemes remain financially healthy. When members receive good ongoing healthcare, their general wellness improves, resulting in fewer serious conditions that are expensive to treat.
Which conditions are covered by PMBs?
The Regulations to the Medical Schemes Act in Annexure A provide a long list of conditions identified as Prescribed Minimum Benefits. The list is in the form of Diagnosis and Treatment Pairs (DTPs).
You can view the full list of 271 medical conditions and 26 chronic conditions, here.
A DTP links a specific diagnosis to a treatment. These mean that each of the 271 PMB conditions are broadly paired to a treatment plan, which is based on proven healthcare treatments and taking affordability into consideration.
The treatment and care of some of the conditions included in the DTP include chronic medicine, such as for TB, HIV-infection and menopausal management.
If you have one of the 26 listed chronic diseases, your medical scheme must cover your medication as well as doctors’ consultations and tests related to your condition. This is all contained in a treatment plan which explains the services the member is entitled to as part of their chronic registration.
Making PMBs work for you
As you can see, PMBs give medical scheme beneficiaries considerable rights as far as healthcare is concerned. However, it is your responsibility to ensure that PMBs work as well for you as they should.
- Educate yourself about your medical scheme’s rules, and the listed medication and treatments for your specific condition
- Investigate which Designated Service Providers (DSPs) are provided by your scheme, as well as which medications are listed for your condition
- Ensure that you authorise your chronic condition with your medical scheme
- Double check that your doctor submits a complete account to your medical scheme and that the correct ICD-10 code is reflected
- Always follow up and check that your account is submitted within four months and paid within 30 days after the claim was received. This is because accounts older than four months are not paid by medical schemes.