What you need to know about PMBs

Did you know that, whatever medical scheme plan you are on, your scheme must, by law, pay in full for the treatment of the prescribed minimum benefit conditions? However, for the scheme to pay in full, you need to follow the correct procedures. Rachel Janssens provides more details

PRESCRIBED minimum benefits (PMBs) are a list of minimum benefits that all medical schemes must provide to members, irrespective of what benefit option they belong to.

By introducing a list of PMBs in 2000, the Council for Medical Schemes aimed to provide people with continuous care to improve their health and well-being. Health care is made more affordable when members have adequate cover and, in the event of a serious illness or major risk event, they do not run out of medical aid cover or lose benefits, forcing them to go to state hospitals for treatment.

PMBs are made up as follows:

• Any emergency medical condition, such as a heart attack or injuries from a motor vehicle accident which, without immediate treatment would result in weakened bodily functions, serious and lasting damage to organs or limbs, or death.

• 270 medical conditions – for example, childbirth.

• 25 defined chronic conditions, such as diabetes and asthma (see list below).

PMBs can be complicated

Not all medical schemes openly disclose what you are entitled to, making it important to speak to your healthcare consultant for guidance so that you are treated fairly. For instance, if you have one of the 25 listed chronic PMB conditions, your medical scheme not only has to cover the medication for that condition, it must also cover doctor consultations and prescribed tests related to that condition.

Your healthcare consultant can help you understand what treatment you are entitled to have covered when it comes to your condition. All medical schemes must cover PMBs in full as regulated by the Council of Medical Schemes. However, in order to contain the cost of providing this benefit, medical schemes may put measures in place to ensure you have the cover you need without placing the scheme at financial risk. They do this by

1. Setting official procedures for certain treatments.

2. Enforcing the use of medication from a prescribed medicine list.

3. Having designated service providers and hospital networks in place for treating and managing PMBs.

Medical schemes are allowed to impose important interventions and restrictions:

• Co-payments (payments from your own pocket) for using another service provider or medication that is not on the prescribed medicine list

• Waiting periods that include PMBs if you have had a break in medical aid cover of more than 90 days or where you have not belonged belonged to a medical scheme in the past.

• Penalties for going outside its network arrangement or failure to pre-authorise your treatment or hospitalisation.

Schemes have to include these arrangements in their rules and if you do not abide by these, you face having to pay all or part of the cost of the treatment yourself.

Always check your benefits Speak to your healthcare adviser or consultant if your hospitalisation, treatment or chronic condition medication, or test falls within the scope of a PMB but has not been funded correctly or from the correct benefit, such as from your savings account instead of the risk benefit.

If you have one of the 25 listed chronic illnesses, your medical aid must cover doctor consultations and prescribed tests related to that condition

Which 25 chronic conditions are covered? Addison’s disease, asthma, bronchiectasis, cardiac failure, cardiomyopathy, coronary artery disease, chronic obstructive pulmonary disorder, chronic renal disease, Crohn’s disease, diabetes insipidus, diabetes mellitus types 1 and 2, dysrhythmias, epilepsy, bipolar mood disorder, hypothyroidism, hypertension, glaucoma, haemophilia, ulcerative colitis, systemic lupus erythematosus, schizophrenia, rheumatoid arthritis, Parkinson’s disease, hyperlipidaemia, multiple sclerosis.