Prescribed Minimum Benefits Must Be Reviewed

The Council for Medical Schemes (CMS) has taken pro-active steps to update Prescribed Minimum Benefits inherent in all medical aid insurance policies. So prescribed minimum benefits must be reviewed.

So Prescribed Minimum Benefits (PMBs) forms an integral part of the Medical Schemes Act (MSA) and dictates that all members of medical schemes – irrespective of their income –  also have access to some health care services.

Also, medical schemes have to provide cover for the diagnosis and treatment of:

  • 270 medical conditions
  • 25 chronic conditions
  • Also, all emergency medical conditions

 

Prescribed Minimum BenefitsAlso, over the years, many members of medical schemes have complained that they have also not been able to obtain information about the 270 PMBs covered by their policies.

So the MSA dictates that medical schemes must inform their members of all benefits inherent in their policies, including the 270 PMB conditions.

It also dictates that all health care providers should inform members of PMB conditions to enable policyholders to lodge claims for treatment falling within the ambit of the MSA.

Members of medical schemes can also access the list of 270 PMBs on the Council for Medical Schemes’ website.

According to Dr Elsabe Conradie, spokesperson for the CMS, the complexity of PMBs makes it difficult to explain in layman’s terms.

Also, the CMS list of 270 PMBs is categorised in “organ system chapters”.

It includes brain, nervous system and mental health conditions, as well as many acute medical disorders, diseases and other illnesses.

Prescribed Minimum Benefits

The list of PMBs is onerous, but here are some examples of prescribed medical conditions that are covered:

  • Acute generalised paralysis, including polio and Guillain-Barre
  • Treatable malign and malignant brain tumours
  • Compound skull fractures
  • Epilepsy
  • Meningitis
  • Muscular dystrophy
  • Strokes
  • Tetanus
  • Cleft palate/lips
  • Various forms of cancer
  • Bell’s palsy
  • Cataract removal/lens implant
  • Retinal disorders
  • Cervical and breast cancer screening
  • Menopausal management
  • Appendicitis
  • Peritonitis
  • HIV infection
  • Botulism
  • Cholera
  • Leprosy
  • Malaria
  • Poisoning
  • Tuberculosis
  • Whooping cough
  • Acute pulmonary heart disease
  • Gangrene
  • Liver transplants
  • Alcohol abuse
  • Anorexia and Bulimia
  • Attempted suicide

 

As stated previously, the list is onerous and the public is urged to visit the CMSs website to obtain further information.

Also, the MSA stipulates that PMBs must be identified by adopting a diagnosis-based approach.

Members of the medical profession should only diagnose symptoms and not take any other factors into consideration, such as how the condition or injury was contracted.

Once diagnosed, doctors can decide upon a course of treatment, whether it be undertaken in a hospital, at an out-patients clinic or doctor’s rooms.

 

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