Prescribed Minimum Benefits (PMB)

Prescribed Minimum Benefits

Prescribed Minimum Benefits (PMB) is set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of what medical aid plan they’re on.

The Medical Schemes Act prescribed that medical schemes have to cover the costs relating to the diagnosis, treatment and care of:

• Any emergency medical condition
• A limited set of 270 medical conditions
• 25 Chronic conditions (defined in the Chronic Disease List)
• Any emergency medical condition
• A limited set of 270 medical conditions
• 25 Chronic conditions (defined in the Chronic Disease List)

Payment of a PMB claim

PMBs covered by the Medical Scheme must be covered at cost, as per Section 29(1) (p) of the Medical Schemes Act 131 of 1998, fromm a specific benefit pool, even if:

• there are scheme exclusions
• benefits are exhausted
• or waiting periods
• there are scheme exclusions
• benefits are exhausted
• or waiting periods

Very important to keep in mind, Medical Schemes may assign Designated Service Providers (DSP) and apply managed care protocols to ensure a cost effective and efficient healthcare services to their members.

The scheme may not pay for a PMB from a savings account or charge a co-payment or levy.

Regulation 8 (2) (a) of the Regulations to Prescribed Minimum Benefits prescribe that a PMB condition will only be paid in full by the Medical Scheme if the treatment was done by a DSP.

According to Regulation 8 (3) however, if the below scenarios applied, a medical scheme has to pay the PMB at cost irrespective if the services was done by a DSP or non DSP.

1. If the treatment was not available from a DSP or could not be provided without unreasonable delay.
2. Immediate (emergency) medical or surgical treatment for a PMB was required under circumstances, or at locations which reasonably prohibited the patient from obtaining treatment from a DSP.
3. There was no DSP within reasonable proximity to the patient’s place of business or personal residence.

Escalation options available if a PMB claim is not paid in full

There are various escalations options available if the medical scheme did not pay or short paid a PMB claim:

1. Contact the scheme to escalate the claim for PMB review and payment.
2. If no payment or feedback were received within a reasonable time period escalate the claim to the scheme’s team leader.
3. Should you still not receive satisfactory feedback escalate the claim to the Council for Medical Schemes (CMS).

Health Market Inquiry (HMI) Recommendations

The HMI Report of September 2019 made mentioned of the complexity and lack of appropriate regulatory interventions of PMB claims and made a number of recommendations such as the following:

1. The list of conditions covered by the PMBs must be revised to make provision for out-of-hospital and cost-effective care which will remove the current incentive to admit patients to hospital, often at higher cost;
2. A simpler design of the benefit package to help members understand their cover;
3. Compulsory care coordination should form part of the benefit package in the form of primary care provider and primary care provider-to specialist referral;
4. That treatment plans and formularies (Health Economic Value Assessments) should be developed for all services covered by the base benefit option.
5. PMBs be reviewed regularly and updated every two years as proposed by the CMS.
6. The introduction of a single, stand-alone, standardised, obligatory ‘base’ benefit package which will replace the current PMBs, but will retain the same philosophy, these are the minimum conditions / services that must be covered and paid for in full by medical schemes.

HMI has also included the below PMB flow diagram in their report