What you need to know about prescribed minimum benefits

Prescribed minimum benefits (PMB) are a list of minimum benefits that all medical schemes must provide to members, irrespective of what benefit option they belong to.

By introducing a list of PMBs in 2000, the Council for Medical Schemes aimed to provide people with continuous care to improve their health and well-being. Healthcare is made more affordable when members have adequate cover and, in the event of a serious illness or major risk event, they do not run out of medical aid cover or lose benefits, forcing them to go to state hospitals for treatment.

PMBs are made up as follows:

• Any emergency medical condition, such as a heart attack or motor vehicle accident which without immediate treatment would result in weakened bodily functions, serious and lasting damage to organs or limbs or even death
• 270 medical conditions, for example childbirth
• 25 defined chronic conditions, such as diabetes or asthma

PMBs can be complicated

Not all medical schemes openly disclose what you are entitled to, making it important to speak to your Healthcare consultant for guidance so you are treated fairly. For instance, if you have one of the 25 listed chronic conditions, your medical scheme not only has to cover the medication for that condition, they must also cover doctor consultations and prescribed tests related to that condition.

Your healthcare consultant can help you understand what treatment you are entitled to have covered when it comes to your condition.

All medical schemes must cover PMBs in full as regulated by the Council of Medical Schemes. However, in order to contain the cost of providing this benefit, medical schemes may put measures in place to ensure you have the cover you need, without placing the scheme at financial risk:

1. Setting official procedures for certain treatments
2. Enforcing the use of medication from a prescribed medicine list
3. Having designated service providers and hospital networks in place for treating and managing PMBs

Medical schemes are allowed to impose important interventions and restrictions:

• Co-payments (upfront payments) for using another service provider or medication that is not on the prescribed medicine list
• Waiting periods that include PMBs if a member has a break in medical aid cover of more than 90 days or where a member has never belonged to a medical scheme in the past
• Penalties for going outside their network arrangement or failure to pre-authorise treatment or hospitalisation

Schemes have to include these arrangements in their rules and if you do not abide by these, you face having to pay all or part of the cost of the treatment yourself.

It is important that you always check your benefits

Speak to your healthcare advisor or consultant if your hospitalisation, treatment or chronic condition medication, or test falls within the scope of a PMB but has not been funded correctly or from the correct benefit, such as from your savings account instead of the risk benefit.

Which 25 chronic conditions are covered?

Rachel Janssens is principal consultant at Alexander Forbes Health