If you are a medical scheme member, you have probably heard the phrase ‘prescribed minimum benefits’ (PMBs). But precisely what are they, who are they for, and when do they get used? It might help to answer some of your questions and concerns and help you to understand what you are entitled to and how PMBs fit into your medical aid cover.
PMBs are a set list of 271 diagnostic conditions and 26 chronic diseases that all medical schemes are required by law to cover under the Medical Schemes Act of 1998 (Act No. 131 of 1998). Included are the expenses for the medical emergency, diagnosis, care, and treatment.
There are three categories of PMB conditions as follows:
Emergency – This sudden, unexpected onset of a health condition requires immediate medical and surgical treatment. If these treatments are not provided, the result could be severe impairment of bodily functions or serious dysfunction of a bodily organ or part. It could also place the person’s life in serious jeopardy.
Chronic – This is any condition that requires one to take long-term, ongoing medication. Examples include asthma, diabetes, cholesterol, and high blood pressure.
Diagnosis – this is where a doctor looks only at the symptoms and not at any other factors – like how an injury was sustained, or condition was contracted. Once the doctor has made the diagnosis, they can decide on the appropriate treatment and care and where the patient should receive the recommended treatment (at a hospital, as an outpatient, or in a doctor’s rooms).
How do I access PMBs?
By being a medical scheme member, you are covered for anything classified as a PMB, provided that your condition qualifies for cover, the required treatments match the treatments stipulated in the defined benefits, and you make use of your scheme’s designated service provider (DSP).
A DSP is a healthcare professional (doctor, pharmacist, hospital, network etc.) that is a medical scheme’s first choice when its members need a diagnosis, treatment or care for a condition.
Most schemes provide a list of their DSP networks for you to check which ones are closest to your area. It is crucial when the treatment is planned or hospital admission is voluntary.
The guidelines specify that in an emergency – where you cannot go to a DSP – you will be treated and stabilised in the closest hospital. Still, your medical scheme may decide to move you to a network hospital once you are able.
Other schemes don’t have DSPs in place. In these instances, the medical scheme must cover the medical costs in full, regardless of the hospital or doctors used.
If your condition falls outside of the PMB parameters, your cover will depend entirely on the benefits available through your health plan. If your health plan does not cover a specific condition or treatment and is also not classified as a PMB, then you will need to self-fund for the condition, treatments or required medication.
Your responsibility as a consumer
PMBs are excellent news for medical scheme beneficiaries and give them considerable rights regarding healthcare. However, as a consumer, you also have specific responsibilities to ensure that PMBs work as well for you as they should.
You must understand how your medical scheme handles PMBs. Learn about the rules of your medical scheme, the medications and treatments (formularies) listed for your specific condition, and who the DSPs are. Most medical schemes have PMB information available on their website for members to peruse.
Learn as much as possible about your condition and available medications and treatments. If a generic drug is available, conduct your research to determine whether it differs from branded medicine.
Do not circumvent the system.
If you must use a general practitioner to refer you to a specialist, do so. Use your medical scheme’s DSPs as much as possible. Unless it is proven that your scheme’s listed drug is ineffective, stick with it.
Be a good consumer by asking questions and following the complaints process if you feel that you are not treated fairly.
Ensure that your doctor submits an accurate account to the medical scheme. The correct ICD-10 code must be reflected when claiming.
Follow up and ensure that your account is submitted within four months and paid within 30 days of receiving the claim.
Accounts older than four months are typically not paid by medical schemes.
Making informed medical aid decisions
Making medical aid decisions must always be informed and based on reliable information. Medical aid quotes should be free and comprehensive. Most people prefer to have information up-front before contacting a broker or consultant.
The reason is simple. When communicating telephonically, you may forget to ask about important benefits, costs and terms & conditions. Suppose you have the options upfront to compare the various benefits plans offered by the medical aid and have the online facility to calculate your monthly contributions. In that case, you already know whether the medical scheme meets your requirements before sorting out finer details telephonically or via email.
Alan Fritz is acting principal officer of Medshield Medical Scheme