There are two main reasons why PMBs were created:
- To ensure that medical scheme beneficiaries have continuous healthcare. This means that even if a member’s benefits for a year have run out, the medical scheme has to pay for the treatment of PMB conditions.
- To ensure that healthcare is paid for by the correct parties. Medical scheme members with 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.
But there are other valid reasons too:
- To provide minimum healthcare to everybody who needs it, regardless of their age, state of health or the medical scheme cover option they belong to.
- PMBs have a part to play in ensuring that medical schemes remain financially healthy. When beneficiaries receive good care on an ongoing basis, their general wellness improves, resulting in fewer serious conditions that are expensive to treat.
- To protect the interests of medical scheme beneficiaries by ensuring, for instance, that schemes first cover essential treatments before setting funds aside for discretionary services.
(Information from the Council for Medical Schemes)