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What are PMBs?

Prescribed Minimum Benefits (PMB) is a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. The aim is to provide people with continuous care to improve their health and well-being and to make healthcare more affordable.

PMBs are a feature of the Medical Schemes Act, in terms of which medical schemes have to cover the costs

related to the diagnosis, treatment and care of:

• any emergency medical condition;
  
• a limited set of 270 medical conditions (defined in the Diagnosis Treatment Pairs);
  
• and- 25 chronic conditions (defined in the Chronic Disease List).
  

When deciding whether a condition is a PMB, the doctor should only look at the symptoms and not at any other factors, such as how the injury or condition was contracted. This approach is called diagnosis-based.

Once the diagnosis has been made, the appropriate treatment and care is decided upon as well as where the patient should receive the treatment (at a hospital, as an outpatient or at a doctor's rooms).

Why do we have PMBs?

There are two main reasons why PMBs were created:

1. To ensure that medical scheme beneficiaries have continuous healthcare. This means that even if a member’s benefits for a year have run out, the medical scheme has to pay for the treatment of PMB conditions.

2. To ensure that healthcare is paid for by the correct parties. Medical scheme members with PMB conditions are entitled to the specified treatments and these have to be covered by their medical scheme, even if the patients were treated at a state hospital.

But there are other valid reasons too:

1. To provide minimum healthcare to everybody who needs it, regardless of their age, state of health or the medical scheme cover option they belong to.

2. PMBs have a part to play in ensuring that medical schemes remain financially healthy. When beneficiaries receive good care on an ongoing basis, their general wellness improves, resulting in fewer serious conditions that are expensive to treat.

3. To protect the interests of medical scheme beneficiaries by ensuring, for instance, that schemes first cover essential treatments before setting funds aside for discretionary services.

What are emergency conditions?

An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or an operation. If the treatment is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death.

In an emergency it is not always possible to diagnose the condition before admitting the patient for treatment. However, if doctors suspect that the patient suffers from a condition that is covered by PMBs, the medical scheme has to approve treatment. Schemes may request that the diagnosis be confirmed with supporting evidence within a reasonable period of time.

Responsibilities:

Medical scheme beneficiaries (Member)

PMBs are very good news for medical scheme beneficiaries and give them considerable rights as far as healthcare is concerned. However, as a consumer you also have certain responsibilities to ensure that PMBs work as well for you as they should.

1. First and foremost, educate yourself about your medical scheme’s rules, the listed medication and treatments (formularies) for your specific condition, as well as who the Designated Service Providers (DSPs) are.

2. Obtain as much information as possible about your condition and the medication and treatments for it. If there is a generic drug available, do your own research to find out whether there are any differences between it and the branded drug.

3. Don’t bypass the system: if you must use a GP to refer you to a specialist, then do so. Make use of your medical scheme’s DSPs as far as possible. Stick with your scheme’s listed drug for your medication unless it is proven to be ineffective.

4. Be a good consumer: ask questions and follow the complaints process if you are not treated fairly.

5. Make sure your doctor submits a complete account to the medical scheme. It is especially important that the correct ICD-10 code is reflected.

6. Follow up and check that your account is submitted within four months and paid within 30 days after the claim was received (accounts older than four months are not paid by medical schemes).

Healthcare providers (Doctors)

Doctors do not usually have a direct contractual relationship with medical schemes. They merely submit their accounts and if the medical scheme does not pay, for whatever reason, the doctor turns to the beneficiary for the amount due. This does not mean that PMBs are not important to healthcare providers nor that they don’t have a role to play in its successful functioning.

1. Doctors should familiarise themselves with ICD-10 codes and how they correspond with PMB codes. If you use the correct ICD-10 code your account will definitely be paid as PMBs enjoy guaranteed medical aid cover.

2. Consider on which option your patients are and what can realistically be covered before recommending a drug or treatment.

3. Alert patients to the fact that their condition is a PMB and encourage them to engage their medical scheme on the matter.

4. Keep proper clinical records of patients so that when a formulary drug or protocol is not effective, or causes adverse side-effects, you can justify your alternative recommendation.

5. Do not abuse PMBs. The result will be an unsustainable private healthcare system with unaffordable contribution increases. Abuse could compel government to consider alternative payment options in the private healthcare sector.

6. Allow your practice to be listed as a DSP.

The “payment in full” concept is there to ensure accessibility of healthcare services for medical scheme beneficiaries if the DSP is not available; it is not a reimbursement model.

Medical schemes

Among other objectives, PMBs want to achieve appropriate healthcare, resulting in lower costs associated with complications and hospitalisation. When beneficiaries are properly taken care of and their illnesses managed, the need for expensive hospitalisation decreases.

1. Medical schemes have a critical role to play in making PMBs work.

2. Schemes have to educate their beneficiaries about PMBs and the benefits that are included in them.

3. Schemes must inform their beneficiaries of their DSPs and keep them updated should any changes occur.

4. Schemes should empower their beneficiaries with information on matters such as the intricacies of rules and the formularies for specific conditions.

5. Medical schemes have to guarantee and ensure reasonable access and availability of DSPs.

6. The public sector cannot be designated as a DSP without the medical scheme ensuring that the necessary service will be available.

For more information, please visit:

https://www.medicalschemes.com/medical_schemes_pmb/index.htm