Medical scheme PMBs (Prescribed Minimum Benefits) are a set of defined benefits mandated by the Medical Schemes Act No. 131 of 1998 to ensure that all medical scheme members have access to certain basic health services, regardless of the benefit option they have selected or their financial status. They refer to a set of defined benefits that all medical schemes are required by law to cover. Medical scheme PMBs are designed to provide people with basic continuous care to improve their health and wellbeing and to make healthcare more affordable.
Medical schemes are required to cover the diagnosis, treatment, and ongoing care of PMB conditions in full, without co-payments or waiting periods, even if a member has depleted their available benefits for the year. However, medical schemes PMBs may be subject to specific protocols and guidelines which differ from one scheme to another. These have been put in place to manage the treatment of PMB conditions.
Medical Scheme PMBs – The Cover
In terms of the Medical Schemes Act, all medical schemes must cover the costs related to the diagnosis, treatment, and care of any emergency medical condition. PMBs must also cover the costs associated with 271 medical conditions, defined in the Diagnosis Treatment Pairs list and 26 chronic conditions defined in the Chronic Disease List. These lists are compiled by the Council for Medical Schemes (CMS).
When deciding whether a condition is one of the prescribed medical scheme PMBs, doctors are required to only consider the symptoms and no other factors, such as how the injury or condition was contracted. This is known as a diagnosis-based approach. Once the diagnosis has been made, the appropriate treatment and care are decided upon as well as where the patient should receive the treatment – whether in a hospital, as an outpatient or in a doctor’s room, for instance.
Potential Difficulties with Medical Scheme PMBs
In respect of some of the diagnosis treatment pairs (DTPs), some medical scheme beneficiaries may find it difficult to know what they are entitled to upfront as medical schemes interpret these benefits differently resulting in a lack of uniformity in the payment of benefits. A benefit definition project is currently being coordinated by the CMS with the aim of defining the benefits inferred by medical scheme PMBs, limiting uncertainty, and providing a guide for the interpretation of the PMB provisions by affected stakeholders.
The guidelines are based on clinical evidence and cost-effectiveness while taking into consideration affordability constraints and the financial viability of medical schemes in South Africa.
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