Your Complete Guide to Prescribed Minimum Benefits

Prescribed Minimum Benefits are the minimum level of healthcare benefits that medical schemes must provide. They are set in place to ensure that members are guaranteed access to a standard of healthcare services and cover a range of medical treatments and services for certain recognised conditions or medical events.

Discover more about Prescribed Minimum Benefits as Bloom discusses this benefit in more detail. 

Why do PMB’s exist?

Prescribed Minimum Benefits (PMBs) are in place to ensure everyone in a medical scheme gets essential healthcare, even when their yearly benefits run out.

Here’s why PMBs are so important:

1. Always Covered: PMBs ensure you’re always covered for certain conditions, even if you’ve used up your plan’s benefits for the year.
2. Paying Right: They also ensure that the costs of these essential treatments are paid for by your medical scheme, not out of your pocket, even if you get treated at a public hospital.

But that’s not all. There are more good reasons for PMBs:

• Healthcare for Everyone: PMBs help everyone get the basic healthcare they need, no matter their health situation, how old they are, or what kind of medical plan they have.
• Keeping Costs Down: Regular care means staying healthier, which helps prevent costly treatments for serious conditions later on.
• Making Sure Costs Are Fair: PMBs guarantee that your medical scheme covers you for essential treatments, so you don’t have to worry about unexpected medical bills, even if you’re treated in a public hospital.

PMBs are here to ensure you get the care you need, keeping you healthy without breaking the bank.

 

What are Prescribed Minimum Benefits, and how does it work?

Prescribed Minimum Benefits, or PMBs, is a list of benefits for which all medical schemes in South Africa have to provide cover in terms of the Medical Schemes Act 131 of 1998 and the Regulations thereto.

To access these benefits:

• Your medical condition must qualify for cover and be part of the defined list of Prescribed Minimum Benefit conditions.
• The treatment needed must match the treatments in the defined benefits.
• You must use the Scheme’s designated service providers.

Prescribed Minimum Benefits include diagnosis and treatment of certain medical conditions classified as critical, chronic or life-threatening.

As of September 2021, there are 270 recognised medical diagnoses and 27 chronic diseases or conditions. However, it must also be noted that while PMBs provide essential cover, they do not cover all expenses related to the services. Depending on the member’s plan and limits, the member may still have to pay out-of-pocket for certain co-payments and deductibles.

All members of medical aid schemes registered in South Africa are eligible for PMBs, regardless of their chosen medical aid plan.

What medical conditions are covered by PMBs?

As per the Medical Schemes Act of 1998, all medical aid schemes are required to cover the costs related to the diagnosis, treatment and care of any life-threatening condition or emergency, a set of 270 medical diagnoses and 26 chronic diseases.

Some of the treatments covered under the set of defined medical diagnoses include:

• Emergency medical services and care
• Management of asthma
• HIV/AIDS treatment and care
• Tuberculosis treatment and care
• Dialysis and kidney transplantation
• Radiation and chemotherapy for cancer
• Palliative care for patients with life-threatening diseases
• Organ transplants and associated care
• Prostheses and orthoses
• Occupational therapy for people with disabilities or injuries
• X-rays and diagnostic imaging for medical purposes

The 26 chronic diseases and conditions covered by PMB’s include the following:

1. Addison’s disease: a hormonal disorder where the adrenal glands don’t produce enough of certain hormones.
2. Asthma: a chronic respiratory disease characterised by inflammation and narrowing of the airways, causing breathing difficulties.
3. Bipolar mood disorder: a mental disorder characterised by episodes of manic and depressive mood swings.
4. Bronchiectasis: a lung condition where one’s airways are permanently inflamed, making it difficult to breathe.
5. Cardiac failure: a heart condition where the heart is unable to pump blood properly.
6. Cardiomyopathy: a disease of the heart muscle that can cause heart failure.
7. Chronic obstructive pulmonary disease: a progressive lung disease making it difficult to breathe.
8. Chronic renal disease: in which the kidneys lose their function over time.
9. Coronary artery disease: where the arteries that supply blood to the heart narrow, reducing blood flow to the heart muscle.
10. Crohn’s disease: an inflammatory bowel disease that affects the lining of the digestive tract, causing severe abdominal pain.
11. Diabetes insipidus: a disorder that causes excessive thirst and urination due to a hormonal imbalance.
12. Diabetes mellitus (Type 1 and Type 2): a chronic metabolic condition in which the body’s inability to produce or respond to insulin adequately causes high blood sugar levels.
13. Dysrhythmia: an abnormal heart rhythm that results in chest pain and can lead to death in some instances.
14. Epilepsy: a neurological disorder that causes seizures or convulsions of varying intensity and severity.
15. Glaucoma: a type of eye condition that damages the optic nerve and can lead to vision loss or blindness.
16. Haemophilia: a bleeding disorder that impairs blood’s ability to clot.
17. HIV/AIDS: a viral infection that attacks the immune system, leading to a range of symptoms and complications.
18. Hyperlipidaemia: a condition in which there are high levels of fats (lipids) in the blood.
19. Hypertension: high blood pressure that can increase the risk of heart disease and stroke.
20. Hypothyroidism: where the thyroid gland doesn’t produce enough thyroid hormones to meet the body’s needs.
21. Multiple sclerosis: where the nervous system can cause muscle weakness, vision problems, and difficulties with coordination and balance.
22. Parkinson’s disease: a progressive neurological disorder that can cause tremors and difficulty with movement and coordination.
23. Rheumatoid arthritis: an autoimmune disease that causes joint pain and swelling.
24. Schizophrenia: a mental illness characterised by disordered thinking, emotions, and behaviour.
25. Systemic lupus erythematosus: an autoimmune disease that affects organs and tissues in the body, causing symptoms like joint pain and fatigue.
26. Ulcerative colitis: an inflammatory bowel disease that affects the lining of the large intestine, causing severe abdominal discomfort.

 

How do exclusions work in terms of PMB’s?

Medical schemes typically won’t cover certain things, like cosmetic surgery or expenses like travel costs and health checks needed for insurance. These are known as exclusions. However, these exclusions don’t apply to Prescribed Minimum Benefits (PMBs). PMBs focus on the diagnosis itself, not on how you got the condition. This means you’re protected from serious health issues, no matter the circumstances.

 

Determining if PMBs cover a medical service or treatment

If a patient’s medical condition is identified as one of the conditions covered by PMBs, the medical healthcare provider will confirm the diagnosis, treatment, and care related to that condition is eligible for coverage under the Prescribed Minimum Benefits. However, patients should be informed of the extent of their cover under PMBs and any out-of-pocket expenses for which they are responsible. In this manner, members can make informed decisions about their healthcare and the financial implications of their treatment.

 

The Benefits and Limitations of Prescribed Minimum Benefits

The benefits of Prescribed Minimum Benefits (PMBs) include:

1. Access to essential healthcare services: PMBs guarantee that all medical aid members have access to healthcare services, regardless of the specific medical aid plan. In this way, patients receive timely and appropriate care for critical, chronic, or life-threatening conditions.
2. Guaranteed coverage: Medical schemes are legally required to cover the diagnosis, treatment, and care of the specific medical conditions included in the PMB list. This means patients can receive necessary healthcare services without worrying about whether their medical scheme will cover the cost.
3. No waiting periods: Patients can receive immediate treatment for their medical condition. This is particularly beneficial for critical and life-threatening conditions where delays in treatment could have serious consequences.
4. No co-payments or deductibles: Medical schemes cannot charge co-payments or deductibles for the PMB benefits. This means that patients do not have to pay any additional out-of-pocket expenses for the diagnosis, treatment, and care of a covered medical condition.

While PMBs provide essential cover for specific medical conditions, there are also some limitations to these benefits, like:

1. Limited cover: PMBs only cover the diagnosis, treatment, and care of the specific medical conditions included in the Prescribed Medical Benefits list. Patients may still need to pay for the diagnosis, treatment, and care of other medical conditions or non-PMB medical services.
2. Limited scope of cover: PMBs only cover the minimum necessary services required. This means some treatments or interventions may not be covered if they are not considered essential for the specific medical condition.
3. Limited access to specialists: PMBs may limit access to specialists, as medical schemes are only required to cover the cost of treatment provided by a specialist in cases where it is necessary for the diagnosis, treatment, and care of the specific medical condition.

 

Designated service providers for PMB’s

Designated Service Providers (DSPs) are healthcare providers like doctors, pharmacists, and hospitals chosen by your medical scheme as the preferred providers for treating Prescribed Minimum Benefits (PMB) conditions.

Here’s why DSPs matter:

1. Using a DSP: If you stick with the DSP your scheme chooses, your treatment costs for PMB conditions are usually covered in full.
2. Choosing a different provider: If you decide to go to a provider other than the DSP, you might have to pay extra. This could be a part of the bill (co-payment) or the difference between what the DSP charges and what your chosen provider charges.

 

Access to DSPs: Medical schemes need to make sure DSPs are easy to reach from your home or work. If a DSP isn’t available within a reasonable distance, your scheme should cover the costs even if you go to another provider.

Emergency Situations: In emergencies or accidents, you can go to the nearest healthcare facility, even if it’s not a DSP, and your scheme should cover the costs.

Quality and Availability: Your scheme must ensure that DSPs can provide the necessary services without making you wait too long. If a DSP can’t treat you, your medical scheme must still cover all costs related to your PMB condition at another provider.

State Healthcare Facilities as DSPs: Not all state facilities are DSPs. Before one becomes a DSP, schemes check that you can access the facility and that it has the necessary treatment and care available.

How Treatment at DSPs Works:

• Direct to DSP: Your scheme may require you to visit a DSP as soon as you are diagnosed. In this case, they cover all related costs from the start.
• Choice of Provider: If your plan allows, you can choose your own doctor. However, choosing a non-DSP provider may lead to a co-payment, depending on your medical scheme’s rules.

 

Affordable Medical Aid with Prescribed Minimum Benefits

Medical aid members are encouraged to understand the importance of Prescribed Minimum Benefits and to familiarise themselves with the list of PMBs in their scheme so they are fully aware of the extent of the coverage provided by their plan. They can also discuss the matter with a trained consultant to determine the specific benefits available to them under their scheme option. 

Contact us to get more information about medical aid plans with PMBs.

 

Medical Content Disclaimer

You understand and acknowledge that all users of the Bloom website are responsible for their own medical care, treatment, and oversight. All content provided on the website, is for informational purposes only and does not constitute medical advice. Neither is it intended to be a substitute for an independent professional medical opinion, judgement, diagnosis or treatment.