You need to know your PMB rights!

September 11, 2018

Imagine a situation where a family member has a heart attack. There’s so much emotional trauma to deal with and then you get the bill for the bypass. Luckily, you have medical aid and heart attacks classified as a prescribed minimum benefit (PMBs). Does that mean your scheme will pay in full? Maybe, but maybe not. You need to know about PMBs.

The long list of PMBs

Martin Neethling, Business Head at Sanlam Healthcare Consultants says, “It is worrying how many people are unaware of what conditions and kind of treatments are covered under PMBs. PMBs are conditions that medical schemes have to cover in full, so long as a prescribed minimum standard of care was provided. The list comprises 25 chronic conditions, 270 medical conditions and medical emergencies. The full list is available on the Council for Medical Schemes website. It can be quite complex to understand, which is where a medical scheme-accredited broker is valuable.”

Know About PMBs

About PMBs and Your RightsNeethling says medical scheme members should familiarize themselves with PMB cover. “But most importantly, medical schemes can also help their members by walking them through the process of what will be covered as a PMB after a doctor’s diagnosis. Sometimes the condition itself can qualify for PMB benefits but treatment given by the doctor may be beyond the level of care that can be covered in full. So medical schemes can play a big role in helping their members make the most cost effective decisions.

All about PMBs

  • About PMBs – How do you qualify for a PMB claim?

Know the code: PMB benefits are based on diagnosis. You need to ask the code for your PMB condition so you can ensure it’s on every claim related to your condition.

  1. a) Try to make sure that the correct form for the test, scan or treatment you’ve received is completed by your doctor and that he or she inserts the right codes.
  2. b) If you have to fill in a PMB form, include all related tests, medicines and consultations, along with their relevant diagnostic codes and the service or chargeable codes. Your doctor may need to help you fill in this form and he or she could charge you for the time this takes.

Your medical scheme will then identify and pay your PMB claim automatically, based on the diagnostic code. Importantly: some schemes might require you to apply for authorisation to avoid a co-payment or the claim being paid from your medical savings account.

  • About PMBs – How should you tackle the long PMB list?

Start by looking at the 15 broad categories and some common examples falling under each. For example:

 

PMB Category Example
  1. Brain and nervous system
Stroke
  1. Eye
Glaucoma
  1. Ear, nose, mouth and throat
Cancer of oral cavity, pharynx, nose, ear, and larynx
  1. Respiratory system
Pneumonia
  1. Heart and vasculature (blood vessels)
Heart attacks
  1. Gastro-intestinal system
Appendicitis
  1. Liver, pancreas and spleen
Gallstones with cholecystitis
  1. Musculoskeletal system (muscles and bones); Trauma NOS
Fracture of the hip
  1. Skin and breast
Treatable breast cancer
  1. Endocrine, metabolic and nutritional
Disorders of the parathyroid gland
  1. Urinary and male genital system
End-stage kidney disease
  1. Female reproductive system
Cancer of the cervix, ovaries and uterus
  1. Pregnancy and childbirth
Antenatal and obstetric care requiring hospitalisation, including delivery
  1. Haematological, infectious and
    miscellaneous systemic conditions
HIV/Aids and TB
  1. Mental illness
Schizophrenia
  1. Chronic conditions
Asthma, diabetes, epilepsy, hypothyroidism, schizophrenia, glaucoma, hypertension

 

  • About PMBs – Does the level of care/type of treatment determine if your medical condition qualifies for PMB payment or not?

Doctors are the only people able to make a diagnosis and are well aware of the codes and their relation to PMBs. The importance of discussing your condition and the level of cover provided by PMBs with your doctor is key to obtaining benefits.  

  •  About PMBs – What would prevent your scheme from paying a PMB account in full?

The PMB conditions are standard BUT the designated service providers and medicines that schemes use can be up to their discretion. This means that if a member uses a provider or treatment that their scheme doesn’t offer, they’ll probably bear some of the expense.

  • About PMBs – How can a medical scheme broker help me?

In more complicated cases, a medical scheme broker plays an important role in championing your cause and helping you understand your rights. For example, a broker can assist if you need a second-tier treatment that falls outside the standard basket of care. You are entitled to it, but your doctor may have to provide clinical motivation before you can claim for it as a PMB. This can also involve an application process.

  • About PMBs – Could PMBs still apply for some medical scheme exclusions?

It depends. For example, cosmetic surgery is an exclusion, but if you contract septicaemia following cosmetic surgery, then your scheme must provide healthcare cover for the septicaemia as it’s a PMB.

  • About PMBs – Can gap cover providers help keep medical aids accountable?

Yes. Your gap cover provider will push back on co-payments or shortfalls related to PMBs and challenge schemes when they believe the scheme should have paid out for the full cost of treatment.

Go here to get your medical aid quote from Medquote. It’s quick to apply!

 

All info was correct at time of publishing