What is a Medical Aid PMB?
PMB is the abbreviation for Prescribed Minimum Benefits. This is a set of conditions, defined within the Medical Schemes Act, says that all medical aids have to cover. Therefore, regardless of a member’s option or plan, medical aids must provide diagnosis, treatment and care for these specified conditions, medical aid PMB include:
- Emergency medical care;
- 270 hospital-based conditions;
- 25 chronic conditions;
- certain out-of-hospital treatments.
Firstly, doctors determine whether a condition is a medical aid PMB through a diagnosis-based approach. This means that they consider only a patient’s symptoms and not any other factors. Medical Aid exclusions do not apply to PMBs. Then, a member who contracts a medical aid PMB condition must be treated for it, regardless of how it has arisen (even if it was caused by an excluded procedure such as plastic surgery).
Medical Aid PMB exist for the following reasons:
- Ensure continuous healthcare – even if no benefits remain for a given year, the medical aid must cover PMB conditions
- Make sure the correct parties are paying for healthcare – medical aids must cover the cost for treatment of these conditions even if their members go to a state hospital
- Provide minimum healthcare to all
- Help ensure the financial health of medical aids – good basic care should improve general wellness and result in fewer serious and expensive conditions
- To protect the interests of medical scheme members by ensuring that essential conditions are treated as a priority.
Once there is a diagnosis for a medical aid PMB condition, the Medical Schemes Act also outlines treatment guidelines. These determine minimum standards of care for each condition.
Designated Service Providers (DSP)
A medical aid will often list healthcare providers that they would prefer members to use for the diagnosis or treatment of their condition. These include doctors, pharmacies, hospitals, etc. Choosing not to use a DSP could result in part-payment of your expenses.
However, medical aids have to ensure that beneficiaries have easy access to DSPs and that they are able to treat the condition without unnecessary delay. State healthcare facilities can be DSPs if they fulfill the necessary criteria.
In the event of an emergency, patients can seek treatment at the nearest healthcare provider, regardless of whether it is a DSP.
A Patient’s responsibility
PMBs are designed to protect both medical aids and their members. Medical Aid members also have a responsibility to ensure they use the system correctly by following these guidelines:
- Educate yourself on your scheme’s rules as they apply to your condition (including details of the relevant DSPs)
- Research your condition to understand treatment options
- Ask questions and use the official complaints process if you encounter problems
- Ensure your doctor submits the correct diagnosis (with the correct codes) to the medical scheme
- Follow up to ensure the claim submission and paid, to avoid penalties.
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All info was correct at time of publishing