Understanding Prescribed Minimum Benefits and the proposed changes to the Medical Schemes Act.
PMBs are a set of defined benefits which ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. By law, Medical schemes are required to pay the costs of PMBs obtained by a member from specified providers in full.
PMBs are a feature of the Medical Schemes Act, which states that 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; and
- 25 chronic conditions
For the 25 listed chronic conditions, if a person has one of these 25 listed chronic diseases (as listed in the Chronic Diseases List), the medical scheme not only has to cover medication, but also the doctor's consultations and tests related to the condition.
When deciding whether a condition is a PMB, doctors should only consider the symptoms and no other related factors, like how the injury or condition was contracted. The approach must be diagnosis-based. Once the diagnosis has been made, the appropriate treatment and care is determined and also where the patient should receive the treatment (at a hospital, as an outpatient or at a doctor's rooms).
Medical schemes often have a list of conditions (for example: cosmetic surgery) for which they refuse to pay, or circumstances under which a member has no cover (for example: travel costs and examinations for insurance purposes) and these are called exclusions. Exclusions do not apply to PMBs! For example, if a patient contracts septicemia after cosmetic surgery the scheme has to provide cover for the septicemia because septicemia is a PMB. Cosmetic surgery remains an exclusion but PMBs are always concerned with the diagnosis and not how the patient got the condition.
Currently, Medical Schemes are obliged by regulation 8 of the Medical Schemes Act to cover the full cost of all prescribed minimum benefits, which they allege leaves them open to over-charging by healthcare providers, including doctors and hospitals, and poses the risk of open-ended liability. Health Minister Aaron Motsoaledi published draft amendments to the Medical Schemes Act Regulations which were criticized for leaving patients vulnerable to potentially huge co-payments on their medical bills, because the schemes liabilities will be limited but not what doctors can charge. The Council for Medical Schemes stated that the changes are aimed to assist schemes and members by setting out exactly how much a scheme is expected to pay if a member voluntarily uses the services of a doctor or hospital outside its network of designated service providers.