The following extracts from the Council for Medical Schemes' website will assist you in understanding Prescribed Minimum Benefits (PMBs). For more consumer information on PMBs, please feel free to visit www.medicalschemes.com.
Consumer Guide: Prescribed Minimum Benefits and Chronic Medication
Click here to access the booklet.
What are PMBs?
Prescribed Minimum Benefits (PMBs) 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 in a doctor's rooms).
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
Which conditions are covered?
The Regulations to the Medical Schemes Act provide a long list of conditions identified as Prescribed Minimum Benefits. The list is in the form of Diagnosis and Treatment Pairs (DTPs).
A DTP links a specific diagnosis to a treatment and therefore broadly indicates how each of the approximately 270 PMB conditions should be treated.
The treatment and care of PMB conditions should be based on healthcare that has proven to work best, taking affordability into consideration. Should there be a disagreement about the treatment of a specific case, the standards (also called practice and protocols) in force in the public sector will be applied. The treatment and care of some of the conditions included in the DTP may include chronic medicine, e.g. HIV-infection and menopausal management. In these cases, the public sector protocols will also apply to the chronic medication.
Which chronic conditions are covered?
The Chronic Disease List (CDL) specifies medication and treatment for the 25 chronic conditions that are covered in this section of the PMBs:
- Addison's disease
Bipolar mood disorder
- Cardiac failure
- Chronic obstructive pulmonary disorder
- Chronic renal disease
- Coronary artery disease
- Crohn's disease
- Diabetes insipidus
- Diabetes mellitus types 1 & 2
- Multiple sclerosis
- Parkinson's disease
- Rheumatoid arthritis
- Systemic lupus erythematosus
- Ulcerative colitis
To manage risk and ensure appropriate standards of healthcare, so-called treatment algorithms were developed for the CDL conditions.
The algorithms, which have been published in the Government Gazette, can be regarded as benchmarks, or minimum standards, for treatment. This means that the treatment your medical scheme must provide for may not be inferior to the algorithms.
If you have one of the 25 listed chronic diseases, your medical scheme not only has to cover medication, but also doctors' consultations and tests related to your condition. The scheme may make use of protocols, formularies (lists of specified medicines) and Designated Service Providers (DSPs) to manage this benefit.
Please note: On Bankmed, these benefits are subject to pre-authorisation, the application of clinical protocols and care plans. This means that you MUST apply for these benefits, or you may lose your entitlement to them. Certain benefits are also only covered in full if you use CareCross Providers (Basic Plan) and Bankmed Network GPs/Bankmed Network Pharmacies (other plans) to access relevant benefits for chronic medication and consultation services. Refer to the benefit schedule for details. Where sublimits are specified for chronic medication, these are first used to pay for all chronic medication, including PMBs, and thereafter continued benefits are only provided for PMBs.
What are your responsibilities as a medical scheme consumer of PMBs?
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 or original drug.
Don't bypass the system: if you must use a GP to refer you to a specialist, then do so. Make use of the Scheme's DSPs (contracted providers) as far as possible. Stick with the Scheme's listed drug for your medication unless it is proven to be ineffective.
Make sure your doctor submits a complete account to the Scheme. It is especially important that the correct diagnosis code (ICD-10 code) is reflected.
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).
Download BHF/DXS ICD-10 Coding Browser here (download is 76mb)