Prescribed Minimum Benefits (PMBs) are a set of specified healthcare benefits under the Medical Schemes Act (131 of 1998) that medical schemes must cover by law. This cover includes funding for the diagnosis, treatment, and ongoing care for listed conditions. PMBs aim to protect members from high healthcare costs for serious illnesses or emergencies.
In this issue of the CMScript we provide valuable information to help you understand your rights and responsibilities regarding PMBs. It also details our upcoming training session on making the most of your PMB coverage.
Why do we have PMBs?
1. To ensure continuous healthcare: Even if yearly benefits are depleted early during the year, the medical scheme must still cover the diagnosis, treatment, and ongoing care for PMB conditions. This ensures that members can receive the necessary care without interruption.
2. To ensure the right party pays: If a condition qualifies as a PMB, the medical scheme must cover the required treatment, even if treatment was received in a public hospital.
Other important reasons:
- To ensure everyone gets basic healthcare, regardless of age, health, or medical scheme benefit option.
- To ensure that medical schemes stay financially stable and help keep members healthier, reducing the risk of more expensive treatments in the future.
What do PMBs cover?
PMBs are divided into three main categories, covering a wide range of medical needs, from emergencies to long-term conditions.
1. Chronic conditions (Chronic Disease List)
PMBs cover treatment for 26 chronic conditions. Some common conditions included are Diabetes (Type 1 and Type 2), High blood pressure (Hypertension), and Asthma. Click here to view CDLs.
2. Medical emergencies
A medical emergency is a sudden condition that requires immediate medical attention and could pose a serious risk to your health or life. Examples include heart attack, stroke, and severe allergic reactions (anaphylaxis).
3. Specified conditions (Diagnosis and Treatment Pairs (DTPs))
There are 271 specific medical diagnoses linked to particular treatments that medical schemes must fund. These conditions can range from common illnesses like pneumonia to more complex issues such as cancer. Examples include appendicitis, tuberculosis, hip fractures, and major depression. Access the DTPs here.
How do PMBs work?
PMBs ensure that members are not charged extra or face out-of-pocket payments when receiving treatment for the listed conditions. While PMBs guarantee necessary care without extra costs, members need to follow a few rules:
Use designated service providers (DSPs): Medical schemes may have agreements with certain doctors or hospitals, called DSPs. Using DSPs ensures full PMB coverage.
Get pre-authorisation: Contact your scheme for specific procedures or treatments related to PMB conditions to ensure that the treatment is fully covered.
Follow treatment protocols: Chronic PMB conditions have a “basket of care” that outlines all the necessary consultations, tests, and treatments that should be shared with your doctor for aligned treatment.
Use formulary medications: A formulary is a list of medications fully covered by your medical scheme for PMB treatment. Using these ensures you receive the right medications at no extra cost; otherwise, a co-payment may apply for non-formulary prescriptions.
Submit necessary documentation: Members may need to submit certain documents, such as referral letters or test results, to verify their PMB condition and ensure funding for the PMB condition.
Understand limitations: While PMBs cover essential services, there may be limits on the number of visits or types of treatments. Review your benefits, DSPs, and formularies each year to avoid unexpected costs.
Your rights as a medical scheme member
Members’ rights under PMBs include the right to receive necessary care without discrimination based on personal factors like age or health and the right to appeal if PMB treatment is denied.
If you believe your medical scheme is not fulfilling its PMB obligations, you can:
- Follow the steps outlined by your medical scheme for filing complaints and appeals.
- Contact the CMS if you have exhausted your scheme’s complaints process. Learn more about CMS’ complaints procedure here.
Download the full CMScript
Educational resources
Members are encouraged to educate themselves further about PMBs and their rights. Useful resources include:
- The Prescribed Minimum Benefits page on the official CMS website.
- The CMS has consumer education booklets in English, Afrikaans, Tswana, Venda and Zulu. Explore the booklets here.
- Patient advocacy groups that provide information on navigating medical scheme systems.
To help you navigate your PMB benefits, the CMS is hosting a dedicated training session where you can get answers to all your questions.