- PMBs are defined by the Medical Schemes Act with the aim to ensure that all medical scheme beneficiaries have access to certain minimum health benefits, regardless of the scheme benefit option they have chosen, their age or the state of their health.
- In terms of the Act, medical schemes have to cover the costs related to the diagnosis, treatment and care of:
- all emergency medical conditions; and
- a limited set of approximately 270 medical conditions as defined in the Diagnosis
Treatment Pairs, which includes 25 chronic conditions as defined in the Chronic Disease List.
- The treating Doctor decides whether a condition is a PMB or not by taking into account the symptoms only – a diagnosis-based approach.
- Out-of-hospital PMB/CDL claims will first be paid from the Member’s applicable benefit category, where applicable, and should this become depleted, then only will the claims be paid from the Scheme’s risk benefit allocation.
- The Chronic Disease List (CDL) specifies the 25 chronic conditions that are covered (see below).
Please note: PMBs are not influenced by Scheme exclusions.
- A PMB condition can only be correctly identified by indicating the appropriate ICD-10 code.
- It is thus of the utmost importance that the correct ICD-10 codes are used in order to ensure that PMB-related services are paid from the appropriate benefits or paid at all.
- The correct ICD-10 codes must also appear on the relevant medicine prescriptions and referral notes to other healthcare service providers.
- An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or intervention. If the treatment/ intervention is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death.
- Subject to application and approval, the Scheme will pay 100% of MST in respect of any services which are voluntarily obtained by a Beneficiary from a service provider other than the DSP for a PMB condition.
- Subject to application and approval, any services in respect of PMBs which are involuntarily obtained by the Beneficiary from a service provider other than the DSP, will be covered in full. (*)
- A Beneficiary will be deemed to have involuntary obtained a service from provider other
than the DSP, if:
- the service was not available from the DSP or would not be provided without unreasonable delay;
- immediate medical or surgical treatment for a PMB condition was required under circumstances or at locations which reasonably precluded the Beneficiary
from obtaining such treatment from a DSP; or
- there was no DSP within reasonable proximity of the Beneficiary’s ordinary place of business or personal residence.
- Except in the case of an emergency medical condition, pre-authorisation shall be obtained by a Member prior to voluntary obtaining a service from a provider other than a DSP in terms of this paragraph to enable the Scheme to confirm that the circumstances contemplated in paragraph (*) above are applicable.
Diagnostic tests for unconfirmed PMB diagnosis:
- Where diagnostic tests and examinations are performed but do not result in the confirmation of a PMB diagnosis, such diagnostic tests or examinations are not considered to be PMB and the costs of such tests or examinations shall be subject to the limits for the various options.
- Benefits in respect of PMBs are unlimited. Benefits in respect of the CDL conditions will be covered 100% if rendered according to the prescribed therapeutic algorithm for the specific condition and treatment plans and claimed with the applicable ICD-10 codes.
- If a Beneficiary knowingly declines the formulary drug and opts to use another drug, a co-payment equal to the difference between the cost of the drug and the Reference Price of the formulary drug will apply.
- Co-payments in respect of PMBs may not be paid out of the personal Medical Savings Account.
DSPs for PMBs:
Any service falling within the PMBs and rendered by the Scheme’s Designated Service Provider (DSP) will be covered in full. If a Member chooses not to use a DSP, a co-payment may be applicable. The Scheme has appointed the following DSPs :
- i) Hospitalisation
- Netcare and Life Healthcare for all options. (A list of hospitals in areas where DSP hospitals are not present, is available on request.)
- Netcare – in respect of radiotherapy facilities.
- State hospitals (Gauteng) as the DSP for transplants and any major medical services which fall within PMBs.
- ii) Specialist Services
- OneCare Specialist Network, practising within the Netcare and Life Healthcare Hospitals. This network will be applicable to in- and out-of-hospital related services. Details of Specialists of the network may be obtained from the Pre-Authorisation Call Centre on 0860 671 060. A list of providers is available on the Scheme’s smartphone app.
- iii) Substance abuse
- SANCA (A list of facilities in areas where SANCA is not present, is available on request.)
- iv) Oxygen and CPAP
- Ecomed Medical
- v) Wound care
- Equity Pharma Holdings
- vi) Prosthetics/Prosthesis/Fixation devices
- Biotronix – Cardiac devices
- Anstem – Soft tissue repairs
- Smith & Nephew – Trauma
- Neospine – Spine (Cervical, Thoracic and Lumbar)
- Johnson & Johnson – All joint replacements and revisions
- Baroque - Vascular stents
- vii) HIV medication
- Medipost – all options
- viii) Oncology medication
- Medipost and Dis-Chem pharmacies – all options