Prescribed Minimum Benefits
(As explained on the CMS website www.medicalschemes.com)
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.
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:
There are two main reasons why PMBs were created:
A DTP links a specific diagnosis to a treatment and therefore broadly indicates how each of the approximately 270 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. These are available on the webpage: https://www.medicalschemes.com/medical_schemes_pmb/conditions_covered.htm
In order to understand the impact of the legislation changes, a clear understanding of the terminology is required:
Designated Service Provider (DSP)
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.
Emergency medical condition
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.
ICD codes
Some of the codes that appear on healthcare providers’ accounts are the ICD-10 codes. These codes indicate to medical schemes 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) and 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 covered. 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.
Why have 26 medical conditions been made PMB’S?
By making these benefits mandatory, the Government, at the recommendation of the Council for Medical Schemes, aims to prevent attempts by schemes at rating members according to the financial risk they pose to a scheme because of the state of their health. The Medical Schemes Act introduced the principle of community rating whereby members of a scheme (or of one of its options) pay the same rates for cover, regardless of their state of health. However, medical schemes have been making chronic benefits available only on options with higher contribution levels. In this way people with chronic conditions were effectively being risk-rated and forced to pay higher amounts for their cover.
Which 26 Illnesses are Covered?
1. Addison’s Disease
2. Asthma
3. Bi-polar Mood Disorder
4. Bronchiectasis
5. Cardiac Failure
6. Cardiomyopathy Disease
7. Chronic Renal Disease
8. Chronic Obstructive Pulmonary Disorder
9. Coronary Artery Disease
10. Crohn’s Disease
11. Diabetes Insipidus
12. Diabetes Mellitus Type 1 & 2
13. Dysrhythmias
14. Epilepsy
15. Glaucoma
16. Haemophilia
17. HIV / AIDS
18. Hyperlipidaemia
19. Hypertension
20. Hypothyroidism
21. Multiple Sclerosis
22. Parkinson’s disease
23. Rheumatoid Arthritis
24. Schizophrenia
25. Systemic Lupus Erythematosus
26. Ulcerative Colitis
The Council for Medical Schemes 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 the CMS in any of the following ways:
Tel: 012 431-0500 / 0861 123 267
Fax: 012 430-7644
E-mail: [email protected]
Mail: Private Bag X34, Hatfield, 0028
By the very nature of our practice and our involvement in serious medical conditions, e.g. diseases of the heart, lung, blood vessels, cancer and the many emergencies we encounter, the chances are that the PMB regulations do apply.
(As explained on the CMS website www.medicalschemes.com)
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.
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:
- any emergency medical condition;
- a limited set of 270 medical conditions (defined in the Diagnosis Treatment Pairs) and
- 26 chronic conditions (defined in the Chronic Disease List).
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.
- 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.
A DTP links a specific diagnosis to a treatment and therefore broadly indicates how each of the approximately 270 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. These are available on the webpage: https://www.medicalschemes.com/medical_schemes_pmb/conditions_covered.htm
In order to understand the impact of the legislation changes, a clear understanding of the terminology is required:
Designated Service Provider (DSP)
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.
Emergency medical condition
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.
ICD codes
Some of the codes that appear on healthcare providers’ accounts are the ICD-10 codes. These codes indicate to medical schemes 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) and 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 covered. 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.
Why have 26 medical conditions been made PMB’S?
By making these benefits mandatory, the Government, at the recommendation of the Council for Medical Schemes, aims to prevent attempts by schemes at rating members according to the financial risk they pose to a scheme because of the state of their health. The Medical Schemes Act introduced the principle of community rating whereby members of a scheme (or of one of its options) pay the same rates for cover, regardless of their state of health. However, medical schemes have been making chronic benefits available only on options with higher contribution levels. In this way people with chronic conditions were effectively being risk-rated and forced to pay higher amounts for their cover.
Which 26 Illnesses are Covered?
1. Addison’s Disease
2. Asthma
3. Bi-polar Mood Disorder
4. Bronchiectasis
5. Cardiac Failure
6. Cardiomyopathy Disease
7. Chronic Renal Disease
8. Chronic Obstructive Pulmonary Disorder
9. Coronary Artery Disease
10. Crohn’s Disease
11. Diabetes Insipidus
12. Diabetes Mellitus Type 1 & 2
13. Dysrhythmias
14. Epilepsy
15. Glaucoma
16. Haemophilia
17. HIV / AIDS
18. Hyperlipidaemia
19. Hypertension
20. Hypothyroidism
21. Multiple Sclerosis
22. Parkinson’s disease
23. Rheumatoid Arthritis
24. Schizophrenia
25. Systemic Lupus Erythematosus
26. Ulcerative Colitis
The Council for Medical Schemes 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 the CMS in any of the following ways:
Tel: 012 431-0500 / 0861 123 267
Fax: 012 430-7644
E-mail: [email protected]
Mail: Private Bag X34, Hatfield, 0028
By the very nature of our practice and our involvement in serious medical conditions, e.g. diseases of the heart, lung, blood vessels, cancer and the many emergencies we encounter, the chances are that the PMB regulations do apply.