Prescribed Minimum Benefits medical cover: What they are, and how do you make use of them?

The law requires your medical aid scheme to provide you with Prescribed Minimum Benefits medical cover, but you also have specific responsibilities when using this cover and the duty to know what it is and how to use it.

Prescribed Minimum Benefits (PMBs) are a set list of 271 diagnostic conditions and 26 chronic diseases that the Medical Schemes Act requires all medical schemes to cover, including the expenses for medical emergencies, diagnosis, care and treatment, says Alan Fritz, acting principal officer of Medshield Medical Scheme.

The three categories of PMB conditions are:

• Emergency, where the sudden, unexpected onset of a health condition requires immediate medical and surgical treatment. If these treatments are not provided, the result could be severe impairment of bodily functions or serious dysfunction of a bodily organ or part. It could also place your life in serious jeopardy.
• Chronic is any condition that requires you to take medication for the long term, such as asthma, diabetes, cholesterol, and high blood pressure.
• Diagnosis, where a doctor looks only at the symptoms and not at any other factors, such as how an injury was sustained, or the condition was contracted. Once the doctor has made the diagnosis, he can decide on the appropriate treatment and care and where the patient should receive the recommended treatment (at a hospital, as an outpatient, or in a doctor’s rooms).

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When are you covered for a prescribed minimum benefit?

As a medical scheme member, you are covered for anything classified as a PMB, provided that your condition qualifies for cover, the required treatments match the treatments stipulated in the defined benefits and you use your scheme’s Designated Service Provider (DSP).

A DSP is a healthcare professional, such as a doctor, pharmacist, hospital or network, that is a medical aid scheme’s first choice when its members need a diagnosis, treatment or care for a condition.

Most schemes provide a list of their DSP networks for you to check which are closest, which is crucial when the treatment is planned or hospital admission is voluntary, but not all schemes have DSPs, Fritz says.

The guidelines specify that in an emergency, where you cannot go to a DSP, you are treated and stabilised in the closest hospital, but your medical aid scheme can decide to move you to a network hospital once you can be moved.

If the scheme does not have DSPs in place, it must cover the medical costs in full, regardless of the hospital or doctors used, according to Fritz.

If your condition is not listed as a prescribed minimum benefit

If your condition falls outside the PMB parameters, your cover will depend entirely on the benefits available through your health plan. If your health plan does not cover a specific condition or treatment and is also not classified as a PMB, you have self-fund for the condition, treatments or required medication.

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Your responsibility as a consumer

Fritz says prescribed minimum benefits are excellent news for medical scheme beneficiaries and give them considerable rights regarding healthcare. “However, as a consumer, you also have specific responsibilities to ensure that PMBs work as well for you as they should. You must understand how your medical scheme handles PMBs.”

He says you should:

• Learn more about the rules of your medical scheme, the medications and treatments (formularies) listed for your specific condition and who the DSPs are. This information is usually available on their websites.
• Learn as much as possible about your condition and available medications and treatments. If a generic drug is available, conduct your research to determine whether it differs from branded medicine, or ask your doctor.
• Do not circumvent the system. Get a referral from your general practitioner to see a specialist and use your medical scheme’s DSPs as much as possible if this is required. Unless it is proven that your scheme’s listed drug is ineffective, stick with it.
• Be a good consumer by asking questions and following the complaints process if you feel that you are not treated fairly.
• Ensure that your doctor submits an accurate account to the medical scheme with the correct ICD-10 code to streamline the claims process.
• Follow up and ensure that your account is submitted within four months and paid within 30 days of receipt. Accounts older than four months are usually not paid by medical schemes.

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Informed medical aid scheme decisions

Your medical aid scheme decisions must always be informed and based on reliable information. Medical aid scheme quotes should be free and comprehensive, as most people prefer to have information upfront before contacting a broker or consultant.

“When you call a broker or consultant, you may forget to ask about important benefits, costs and terms and conditions. If you have the options upfront to compare the various benefits plans offered by the medical aid scheme and the online facility to calculate your monthly contributions, you will already know whether the medical scheme meets your requirements before sorting out finer details.”