Can a lack of knowledge regarding PMBs mean that you end up paying for bills that your medical scheme should cover?
As per the Council for Medical Schemes (CMS), Prescribed Minimum Benefits (PMB) are a set of defined benefits to ensure 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.
Medical schemes have to cover the costs related to the diagnosis, treatment and care of:
any emergency medical condition;
a limited set of 271 medical conditions and
26 chronic conditions.
But the questions many members ask are: what exactly are Prescribed Minimum Benefits and how can one benefit?
Over the past few weeks we’ve seen articles in the media about medical schemes, the healthcare providers and the Council for Medical Schemes (CMS) debating the issue regarding PMBs and who is responsible for payments, what rates need to be charged, etc. A task team has been established by the CMS and other role players in the healthcare market to establish a code of conduct, and how and why PMBs need to be implemented. The task team consists of representatives from the Department of Health, health associations and practitioners, and consumer groups. However, the establishment of this team does not mean the CMS will back down from its decision to penalise schemes and administrators for non-compliance. Full compliance with this legislation is still non-negotiable.
Marcel du Toit, CEO of Optivest Health Services, says you as the member have the legislation on your side; medical schemes need to pay for the diagnosis, treatment and care of the list of PMB conditions as compiled by the Council for Medical Schemes. Du Toit says furthermore that last year the CMS announced penalties for schemes and administrators for non–compliance regarding PMBs and claim pay-outs.Such non-compliance could result in the de-registering of the scheme or administrator.
But, in order for you to enjoy the full benefit, you as the member need to understand the basic rules regarding PMBs. If you are diagnosed with a condition such as multiple sclerosis, you know there will be cost implications. Perhaps you are only on a basic hospital plan, so what now? Remember, many chronic diseases such as multiple sclerosis are covered under Prescribed Minimum Benefits, which means by law any medical aid has to cover them. Around 26 chronic diseases are actually listed in the Chronic Diseases List (CDL). This ensures people receive the care they need.
“If you are worried about the cost of treatment, consult your medical aid broker or medical scheme, who will explain these Prescribed Minimum Benefits in detail,” says du Toit.
He explains: "There are some rules the medical scheme can impose, like the service providers from whom you may obtain your medication, called Designated Service Providers (DSPs), and chronic medication benefit programmes of which you should be part of. The best thing to do is to read up on the regulation and then find out how your particular medical scheme applies it in practice. Don't be afraid to ask questions and demand full answers”.
Example - As simple as falling from a tree (Source: Council for Medical Schemes)
When 11-year-old Johnny fell from a tree and fractured his left arm, his dad took him to their medical scheme’s DSP hospital.
The doctor on duty in the emergency room treated the fractured bone under local anaesthesia, applied a plaster of Paris cast and sent Johnny home with a prescription for pain tablets. The medical scheme informed Johnny’s dad that they were not going to pay the trauma facility accounts. In their opinion the member qualified for PMB services only if the person concerned was hospitalised.
Fortunately for Johnny’s dad, this is incorrect. PMB-related services are not restricted to a specific setting in which care should be provided. Therefore, PMB-related services can take place in the emergency room, at a clinic or in a GP’s rooms – in fact, wherever it is clinically appropriate.
Remember, when signing an application form to join a medical scheme you enter into a binding contract. Make sure you read all the fine print as well, as ultimately it is the member’s responsibility to know for what he is signing. With regard to topics such as PMBs, ask questions, read as much as you can, about them. A good place to start will be The Council for Medical Schemes website, and even a new site, www.medicalaid.co.za, which was launched recently. They cover all medical aid-related information such as how to choose an option, hospital plan vs comprehensive cover, and contain a great section on real-life examples of PMBs.
If understood and used correctly, Prescribed Minimum Benefits could ease many of the members’ concerns about payments and conditions not being covered, says Du Toit.