Towards the end of the year is traditionally the time when members of medical aid schemes assess their benefits, consider their personal and their family’s healthcare needs in the year ahead, and may even shop around for a better deal – either a different option with the same medical scheme or a different scheme altogether.
“But when you are weighing up different options,” says Dr James Arens, Clinical Operations Executive of Pro Sano Medical Scheme, “make sure that you are fully aware of what minimum benefits you qualify for – or, as we call them in South Africa, Prescribed Minimum Benefits (PMBs).”
What are PMBs?
According to the Council for Medical Schemes, the body that regulates medical schemes in South Africa, Prescribed Minimum Benefits (PMBs) are a set of defined benefits that ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected.
PMBs are a feature of the Medical Schemes Act. One of the reasons they were created is to ensure that medical scheme beneficiaries have continuous healthcare. This means that even if a member’s benefits for the year have run out, their medical scheme is obliged to pay for the treatment of PMB conditions, which include the diagnosis, treatment and care of any emergency medical condition. The PMBs include a limited set of 270 medical conditions which must be diagnosed and include conditions such as stroke, heart attack, fractured hip, mental illness such as schizophrenia and various types of cancer.
Medical schemes often have a list of conditions, such as cosmetic surgery, for which they will not pay, or circumstances, such as travel costs and examinations for insurance purposes, under which a member has no cover. These are called exclusions. Exclusions, however, do not apply to PMBs. If you contract septicaemia, a serious blood infection, after cosmetic surgery, for example, your scheme has to provide healthcare cover for the septicaemia treatment because septicaemia is a PMB. (Cosmetic surgery remains an exclusion.)
Finally, PMBs also cover 26 specific chronic disease conditions (such as asthma, heart failure, chronic kidney, hypertension and diabetes mellitus).
“All members of a medical aid scheme should be fully aware of the minimum benefits set out by law, and therefore what their scheme is expected to pay for,” says Dr Arens. “Members who have any of the PMB conditions are entitled to the specified treatments and these have to be covered by their medical scheme, even if the patients were treated at a state hospital. In this way, members can rest assured that minimum healthcare will be provided if they need it, regardless of their age, state of health or the medical scheme cover option they belong to.”
(August 2010, Issued by Global Interface on behalf of Pro Sano Medical Scheme)