A guide to understanding Prescribed Minimum Benefits
How to navigate PMBs effectively
13 August 2024
JOHANNESBURG - Healthcare cover can be a maze of jargon and complexities, leaving many consumers feeling overwhelmed, but one term you should grasp is Prescribed Minimum Benefits (PMBs). They are crucial components of medical schemes in South Africa – mandated by the Medical Schemes Act – that ensure members have access to essential healthcare services without fear of running out of benefits for critical conditions.
But what exactly are PMBs? Prescribed Minimum Benefits (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 No. 131 of 1998. Included are the expenses for the medical emergency, diagnosis, care, and treatment. PMBs aim to ensure that medical scheme beneficiaries receive continuous cover for life-threatening diseases or events. This means that even if a member's annual benefits are exhausted, the medical scheme must cover the PMB condition's treatment, provided the condition meets the specific requirements of the Medical Schemes Act.
Navigating PMBs effectively
All Medshield members are entitled to PMB cover, irrespective of their selected benefit option. Medshield covers the cost of treatment for a PMB, provided that the services are rendered by one of Medshield's Designated Service Providers (DSP) and that the treatment is PMB Level of Care, adheres to your chosen benefit option and the Scheme Rules. Navigating PMBs effectively involves understanding a few key points:
- Firstly, ensure your condition qualifies as a PMB or falls under the Chronic Disease List. This way, you're entitled to diagnosis, treatment, and care coverage.
- Secondly, familiarise yourself with your scheme's rules and benefit options. Following these guidelines is crucial to smoothly accessing PMB benefits.
- Thirdly, communication with healthcare providers and scheme representatives is vital. Whether obtaining authorisations or submitting claims, staying informed and engaged ensures you receive the care you're entitled to.
In practical terms, PMBs cover both in-hospital admissions and out-of-hospital management. For in-hospital admissions, patients must follow Medshield's hospital authorisation process to choose a hospital within the Hospital Network. Specialist services are paid at the Scheme rate, but doctors can request cost-based payment if the scheme rate doesn't cover the total claim via pmbapplications@medshield.co.za. Gap cover is the ideal solution to cover the difference between the Scheme rate and the healthcare providers' cost.
Out-of-hospital care requires adherence to your Care Plan, with additional treatments necessitating a PMB application. If you have a Chronic Disease List (CDL) condition and need additional treatment, your doctor must complete a PMB Application form and motivation letter. This process helps obtain approval for further treatment and grants you a new Care Plan with specified treatment. The PMB Application form is available under the member tab on the Scheme website at http://www.medshield.co.za/.
Essential checklist to access benefits
At Medshield, we're committed to transparency and providing comprehensive information to help you navigate your healthcare journey. With a range of benefit plans tailored to diverse needs, we prioritise affordability and accessibility, ensuring all members receive the care they deserve.
As such, here is Medshield's essential checklist to access benefits for a PMB condition:
- The condition must qualify as a Prescribed Minimum Benefit - be on the Chronic Disease List or be one of the 271 DTP (Diagnosis and Treatment Pair) conditions - or be a life-threatening medical emergency.
- When diagnosed, your treatment must match those in the defined benefits available on the PMB list.
- Using the Designated Service Providers as specified on your selected benefit option is essential. If your option has preferred networks for chronic medicine, hospitals, pharmacies or healthcare providers, you must obtain services from those providers; otherwise, you might be liable for a portion or the whole cost, or medical schemes might deduct it from your Day-to-Day allocation or Savings portion.
- Scheme Rules apply – even if your condition is identified as a PMB, you must follow the rules set out by your benefit option and medical scheme.
- Review the requirements in your Benefits Guide to ensure your treating doctor completes a PMB application form when required.
- South African consumers need to comprehend what PMBs entail: Consumers can access necessary medical treatments by ensuring proper diagnosis and registration and understanding of covered treatments and care under PMBs.
- Affordable and necessary care: PMBs ensure access to necessary healthcare services, even for individuals with limited financial means.
- Protection from denial of coverage: Medical schemes are legally obligated to cover PMBs and PMB LOC (level of care), protecting consumers from denial of necessary treatments or services.
- Informed decision-making: Knowing which conditions and treatments are covered under PMBs empowers consumers to make informed decisions when choosing medical schemes and benefit options.
- Members' rights: PMBs protect members' rights to a minimum level of healthcare regardless of their selected plan or benefit option.
In conclusion, PMBs are more than just a healthcare term – they're a lifeline for South African consumers, guaranteeing access to essential medical aid cover when they need it most. PMBs hold immense importance in guaranteeing a minimum level of coverage for specific medical conditions. Despite the prospect of guaranteed coverage, you must be aware of the specific requirements outlined in your benefit option and medical scheme rules. Be a good consumer by asking questions and following the complaints process if you feel you are not treated fairly. By demystifying PMBs and understanding their significance, you can confidently take charge of your healthcare.
FIN
(890 words)
