What you need to know about PMB’s

Healthcare is a serious expense and one that many can’t afford. This has seen the health insurance industry thriving as people are increasingly seeking health cover in the event of misfortune. But even these insurance plans are limited, in order to ensure that members are covered fairly Prescribed Medical Benefits (PMBs) were introduced. Moneybags journalist, Danielle van Wyk, explores the ins and outs of PMBs.

What is a PMB?

“PMBs were introduced into the Medical Schemes Act to ensure that members of medical schemes would not run out of benefits for certain conditions and find themselves forced to go to state hospitals for treatment,” stated the Board of Healthcare Funders (BHF).

Prescribed Minimum Benefits (PMB) 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.

“The Prescribed Minimum Benefit (PMB) programme was introduced into the Medical Schemes Act (MSA) in 2004 to assist medical schemes in managing the costs related to chronic or serious illness,” explains Dr Bobby Ramasia, principle officer of Bonitas Medical Fund.

Typically, the National Department of Health (DoH) decides on them. “It started as an essential hospital package and then subjectively benefits were added. Currently its very specialist and hospi-centric. It is adult centric, diagnosis based (thus “discriminatory”) and poorly designed. The individual items listed in the PMBs are not adequately specified and thus leading to different interpretation of entitlement,” notes the BHF.

They are set out in the Regulations to the Medical Schemes Act, and the list can only be changed through an amendment to these Regulations, explains head of research and development at Discovery Health, Deon Kotze.

What do they cover?

PMB’s usually cover diagnosis, treatment or ongoing care for, “Any emergency medical condition that poses a threat to life or limb; 27 chronic conditions (e.g. diabetes and hypertension); and 270 medical conditions, referred to as DTPMBs (Diagnosis Treatment Pairs),” divulged Kotze.

“All PMBs are accorded the same level of importance. However, there is a prevalence hypertension, diabetes, asthma, depression and HIV among Bonitas members,” stated Ramasia.

Costing of PMB’s?

The costing of PMB’s are done in line with a scheme’s approach to the cover for these set out PMBs. The member’s plan choice may also have a bearing on the costing implemented by the scheme, advises Kotze.

“In the case of the Discovery Health Medical Scheme (DHMS), all plans are fully compliant with the PMB requirements, and some plans offer benefits that extend beyond the minimum cover required for PMBs,” Kotze highlights.

“The PMB’s haven’t been reviewed since 2002.  The regulation, however, requires the DoH to review them every two years,” adds the BHF.

Advice to members 

The below are a few tips according to Discovery that could assist you in PMB claim pay-outs:

Hospital treatments

-“In any life threatening emergency, go to any provider. Your claims from the hospital and treating doctors will be covered in full on most DHMS plans. If you are on a network plan and/or if you are using a non-contracted doctor, once you are stabilised you should check with DHMS to see if you need to be moved to a network provider.

“If you are on a network plan and choose to remain in a non-network hospital, you may face a co-payment for your treatment after you are fully stabilised. Similarly, on any plan, if you are using doctors who are not contracted with DHMS, you may face a co-payment on the doctor’s bills,” statesKotze.

Should you however be in a waiting period, you may have access to ‘some PMB cover for in hospital treatment.’

“Please consult your broker or the DHMS website to obtain full information on your situation while in the waiting period. If you are in a waiting period and are entitled to PMB cover, you may use any hospital and any provider during a life threatening emergency and you will be covered in full,” advises Kotze.

However, in the case of the situation not being of a life threatening nature or post- stabilisation, it is always advisable to consult with your medical insurance provider to ensure that you are making use of a ‘fully covered hospital and doctors’.

“If you elect to continue to use hospitals and doctors who are not fully covered, you may face a co-payment,” says Kotze.

Out of hospital treatments

-Should you be diagnosed with a chronic condition it is always advisable that you consult both your doctor and your medical aid insurer as with different schemes and medical plans there are potentially options and facilities available to chronic patients.

“In order for members to get the maximum benefit from PMB cover, they need to be as informed as possible,” advises Ramasia.

For more on PMB’s and the regulation thereof members are advised to visit the Council of Medical Schemes website.