Your guide to prescribed minimum benefits

Prescribed minimum benefits (PMB) are a feature of the Medical Schemes Act 131 of 1998 and aim to ensure that all medical scheme members have at least minimum coverage for certain health services.

PMB are granted for 271 specified medical conditions, 26 chronic diseases as listed on the Chronic Diseases List (CDL) and life-threatening emergencies. Medical schemes must cover the costs of the diagnosis, treatment and care of these conditions.

The Medical Schemes Act which first introduced PMB came into effect on 1 January 2000.

According to the Council for Medical Schemes (CMS), the medical conditions that qualify for PMB are the most common, life-threatening conditions for which cost-effective treatment would sustain and improve the quality of the patient’s life. This includes conditions such as various types of cancer, HIV/Aids and TB, and chronic diseases such as asthma, epilepsy and hypertension.

The full list of PMB conditions covered is available on the CMS website. The list is in the form of Diagnosis and Treatment Pairs (DTPs) and broadly indicates how each of the conditions should be treated.

Medical scheme members qualify for PMB based on the clinical criteria linked to the condition, and they are entitled to specified treatments that are covered by their schemes.

Treatment algorithms have been developed for the various CDL conditions and serve as benchmarks for treatment that medical schemes have to adhere to. These algorithms are also available on the CMS website.

In the case of non-CDL conditions, schemes may develop treatment protocols by listing the investigations, treatments and medication that are covered as PMB level of care. One of the benchmarks when deciding on PMB level of care – as outlined in the Regulations under the Medical Schemes Act – is what the prevailing treatment in State facilities amount to. In addition, the treatment protocols linked to PMB conditions must be based on outcomes as well as cost-effectiveness and affordability (regulation 15Ha).

PMB cover for Medihelp members

Medihelp provides cover for PMB conditions on all our medical aid plans. In order to benefit from PMB, a patient must meet the following requirements:

• The condition must be part of the PMB list and fulfil the clinical criteria as outlined in the treatment protocol.
• The requested treatment must fall within the ambit of cost-effectiveness and affordability as outlined in the Regulations.
• The Scheme’s designated service providers (DSPs) must be used to ensure full cover. A DSP is a doctor, pharmacist or hospital that is a medical scheme’s first choice when its members need a diagnosis, treatment or care for a PMB condition.

There are certain steps to follow in order to obtain PMB for consultations and services, medicine, hospitalisation and emergencies. This includes registering the illness with Medihelp and getting pre-authorisation for hospital admissions and services in respect of PMB conditions, making use of DSPs, and ensuring that the treating doctor or healthcare provider follows the PMB treatment guidelines and algorithms as specified in the Regulations (CDL conditions) or the Scheme’s outcomes-based protocols, as described above.

There may be instances where a member has no cover for PMB conditions, for example when joining Medihelp without having any previous medical scheme membership or joining more than 90 days after leaving a previous medical scheme, in which case a waiting period may be imposed. Should a waiting period in respect of a specific medical condition apply to your membership, you may in some cases still qualify for PMB if you meet the PMB requirements stipulated in the Act.

Sources:

https://www.medicalschemes.co.za/resources/pmb/

https://www.medicalschemes.co.za/pmb-questions/

https://www.medihelp.co.za/quick-answers/pmb-and-cdl