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Minimum Healthcare to Everybody PMBs provide minimum healthcare to everybody, regardless of age, state of health or medical scheme cover option Continuous and Affordable Care PMBs ensure continuous and affordable healthcare to improve the health and well-being of beneficiaries. Sustainable Medical Schemes PMBs play a role in ensuring that medical schemes remain financially healthy.

What are Prescribed Minimum Benefits?

Prescribed Minimum Benefits (PMBs) are 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:

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).

PMB Definitions

The legislation governing the provision of the prescribed minimum benefits (PMBs) is contained in the regulations enacted under the Medical Schemes Act, 1998 (Act No. 131 of 1998).

In respect of some of the diagnosis treatment pairs (DTPs), medical scheme beneficiaries find it difficult to know their entitlements in advance, while medical schemes interpret these benefits differently, resulting in a lack of uniformity of benefit entitlements.

The benefit definition project is coordinated by the CMS, with the aim to define the PMB package; and to guide the interpretation of the PMB provisions by relevant stakeholders.

The guidelines are based on evidence of clinical and cost effectiveness, taking into consideration affordability constraints and financial viability of medical schemes in South Africa.

PMB Details

Explore detailed information on PMBs below, should you require any other assistance feel free to contact us.

Why do we have PMBs?

There are two main reasons why PMBs were created:

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; and

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:

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;

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;

and 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.

Which conditions are covered?

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).

 

A DTP links a specific diagnosis to a treatment and therefore broadly indicates how each of the approximately 271 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.

 

Here is an example of a DTP as it appears in the Medical Schemes Act:

The 271 conditions that qualify for PMB cover are diagnosis-specific and include a range of ailments that can be divided into 15 broad categories:

No exclusions

Medical schemes often have a list of conditions – such as cosmetic surgery – for which they will not pay, or circumstances – such as travel costs and examinations for insurance purposes – under which a member has no cover. These are called exclusions. Exclusions, however, do not apply to PMBs. If you contract septicaemia after cosmetic surgery, for example, your scheme has to provide healthcare cover for the septicaemia part because septicaemia is a PMB. (Cosmetic surgery remains an exclusion.) PMBs are concerned about the diagnosis; it doesn’t matter how you got the condition.

Which chronic diseases 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:

Chronic renal disease

Addison’s disease

Asthma

Bronchiectasis

Cardiac failure

Cardiomyopathy

Chronic obstructive pulmonary disorder

Coronary artery disease

Crohn’s disease

Diabetes insipidus

Diabetes mellitus types 1 & 2

Dysrhythmias

Epilepsy

Bipolar Mood Disorder

Hypothyroidism

Hypertension

Glaucoma

Haemophilia

Ulcerative colitis

Systemic lupus erythematosus

Schizophrenia

Rheumatoid arthritis

Parkinson’s disease

Hyperlipidaemia

Multiple sclerosis

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.

 

Access the chronic disease list algorithms here.

What happens in an emergency?

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.

Why are Designated Service Providers important?

A Designated Service Provider (DSP) is a healthcare provider (doctor, pharmacist, hospital, etc) that is a medical scheme’s first choice when its members need diagnosis, treatment or care for a PMB condition.

 

If you choose not to use the DSP selected by your scheme, you may have to pay a portion of the bill as a co-payment. This could either be a percentage co-payment or the difference between the DSP’s tariff and that charged by the provider you went to.

 

Medical schemes have to ensure that it is easy for beneficiaries to get to the DSPs. If there is no DSP within reasonable distance of your work or home, then you can visit any provider and the scheme is obliged to pay.

 

When you suffer an emergency condition, or are involved in an accident, you may go to the nearest healthcare facility for treatment, even if it is not a DSP. Your scheme will have to cover the costs.

 

Schemes also have to ensure that the DSPs of their choice can deliver the services needed and without members having to wait unreasonably long. Where a DSP is unable to accommodate or treat a member, the medical scheme remains liable for all the costs of treating the PMB condition at a non-DSP.

 

The State’s healthcare facilities can be, but are not necessarily, DSPs. Before they can be listed as such, schemes have to make sure that their beneficiaries can get to the facilities and that the required treatment, medication and care are available and accessible.

 

Treatment at DSPs can be handled in two ways:

  1. Schemes can insist that you go to a DSP as soon as your condition is diagnosed, in which case they cover the costs from the start. Treatment at a DSP will be covered in full by the medical scheme under the PMB conditions when delivered according to scheme protocols and formularies.
  2. If your benefit option allows for this, you can be treated by the doctor of your choice. If you choose to use a provider of your choice for these services, the scheme may apply a co-payment, as registered in their rules.

What are ICD-10 codes?

One of the types of codes that appear on healthcare provider accounts is known as ICD-10 codes. These codes are used to inform medical schemes about what conditions their members were treated for so that claims can be settled correctly.

ICD-10 stands for International Classification of Diseases and Related Health Problems (10th revision). It is a coding system developed by the World Health Organisation (WHO), that translates the written description of medical and health information into standard codes, e.g. J03.9 is an ICD-10 code for acute tonsillitis (unspecified) and G40.9 denotes epilepsy (unspecified).

 

When you join a medical scheme, you choose and pay for a particular benefit option. This benefit option contains a basket of services that often has limits on the health services that will be paid for. Because ICD-10 codes provide accurate information on the condition you have been diagnosed with, these codes help the medical scheme to determine what benefits you are entitled to and how these benefits could be paid.

 

This becomes very important if you have a PMB condition, as these can only be identified by the correct ICD-10 codes. Therefore, if the incorrect ICD-10 codes are provided, your PMB-related services might be paid from the wrong benefit (such as from your medical savings account), or it might not be paid at all if your day-to-day or hospital benefits limits have been exhausted.

 

ICD-10 codes must also be provided on medicine prescriptions and referral notes to other healthcare providers (e.g. pathologists and radiologists) who are not all able to make a diagnosis. Therefore, they require the diagnosis information from your referring doctor so that their claim to your medical scheme can also be paid out of the correct pool of money.

 

Important note: Medical schemes are obliged by law to treat information about members’ conditions with the utmost confidentiality. They are not allowed to disclose even ICD-10 codes to any other party, including employers or family members.

List of All PMB Conditions

Click the button below to download a full list of PMB conditions covered

What are your responsibilities
and those of providers?

Medical scheme beneficiaries

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.

  • 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.
  • 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.
  • 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.
  • Be a good consumer: ask questions and follow the complaints process if you are not treated fairly.
  • Make sure your doctor submits a complete account to the medical scheme. It is especially important that the correct 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).

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

  • Schemes have to educate their beneficiaries about PMBs and the benefits that are included in them.
  • Schemes must inform their beneficiaries of their DSPs and keep them updated should any changes occur.
  • Schemes should empower their beneficiaries with information on matters such as the intricacies of rules and the formularies for specific conditions.
    Medical schemes have to guarantee and ensure reasonable access and availability of DSPs.
  • The public sector cannot be designated as a DSP without the medical scheme ensuring that the necessary service will be available.

Healthcare providers

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.

  • Doctors should familiarize 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.
  • Consider on which option your patients are and what can realistically be covered before recommending a drug or treatment.
  • Alert patients to the fact that their condition is a PMB and encourage them to engage their medical scheme on the matter.
  • 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.
  • 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.
  • 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.

CMS can help

PMBs can be a rather complicated subject and your medical scheme might not be able to answer all your questions. Sometimes, your medical scheme may be reluctant to provide you with the cover you are entitled to for a PMB condition and you need someone to champion your cause.

Do not despair. The Council for Medical Schemes (CMS) was established to supervise medical schemes in South Africa. In this role, its first priority is to protect the rights of consumers and to ensure that they are treated fairly.

Therefore, if you have a problem with your medical scheme, contact us in any of the following ways:

012 531 5000
0861 123 267
Fax 0124307644
support@medicalschemes.co.za
Postal Address Private Bag X34, Hatfield, 0028

Further details on PMB are provided for beneficiaries, schemes, and providers here

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