Prescribed Minimum Benefits Explained
Many members and even healthcare providers still don’t understand how Prescribed Minimum Benefits (PMBs) work, what benefits PMBs hold, and also what the ‘dark side’ of PMBs is. The Council for Medical Schemes put together a number of FAQs to help educate members on their rights and responsibilities in terms of PMBs. Let’s look at a few of these…
Why are some chronic illnesses covered and some not?
The diseases that have been chosen are the most common, they are life-threatening, and are those for which cost-effective treatment would sustain and improve the quality of the member’s life.
Can my scheme insist that it will only fund treatment that follows the appropriate protocol?
Yes. Treatment algorithms (benchmarks for treatment) for all PMB conditions have been published in the Government Gazette. Your scheme may decide for which medicines it will pay for each chronic condition, but the treatment may not be below the standards published in the treatment protocols. If your scheme’s cover conforms to that standard and you and your doctor decide that you should rather use different medication, then you may have to pay a co-payment towards the cost of that medicine. Your medical scheme must, however, pay for the treatment if your doctor can prove that the standard medication is ineffective or detrimental to your condition.
Your medical scheme may develop protocols to manage the use of benefits. Such protocols would specify, for example, types of tests, investigations and number of consultations. Members who might need more frequent or extra services than provided for in the protocols, can appeal to their scheme for these to be covered. The scheme’s appeal process might include a motivation from the treating doctor that explains the clinical reasons for the additional services.
Can my scheme refuse to cover my medication if I need, or want, a brand other than that which the scheme says it will pay for?
Yes, the medical scheme may refuse to cover a part of the expenses. Your scheme may draw up what is known as a formulary – a list of safe and effective medicines that can be prescribed to treat certain conditions. The scheme may state in its rules that it will only cover your medication in full if your doctor prescribes a drug on that formulary. Generally speaking, schemes expect their members to stick to the formulary medication.
Often the medicines on the list will be generics – copies of the original brand-name drug – that are less expensive but equally effective. If you want to use a brand-name medicine that is not on the list, your medical scheme may foot only part of the bill and you will have to pay either the difference between the price of the medication you use and the one on the formulary, or a percentage co-payment as registered in the scheme rules.
If you suffer from specific side-effects from drugs on the formulary, or if substituting a drug on the formulary with one you are currently taking affects your health detrimentally, you can put your case to your medical scheme and ask the scheme to pay for your medicine. You can also appeal to the scheme if the formulary drug is ineffective and does not have the desired effect. If your treating doctor can provide the necessary proof and the scheme agrees that you suffer from side-effects, or that the drug is ineffective, then the scheme must give you an alternative and pay for it in full.
Can my scheme make me pay a co-payment or levy on a PMB?
No, your scheme cannot charge you a co-payment or levy on a PMB if you follow the scheme formulary and protocol. However, if your scheme appoints a Designated Service Provider (DSP) and you voluntarily use a different provider, your scheme may charge you the difference between the actual cost and what it would have paid if you had used the DSP or the percentage co-payment as registered in the scheme rules.
Can schemes still set a chronic medicine limit?
Yes, your scheme can set a limit for your chronic medicine benefit. Any chronic medication you claim for will then reduce that limit, regardless of whether or not it is one of the PMB chronic conditions. However, if you exhaust your chronic medicine limit, your scheme will have to continue paying for any chronic medication you obtain from its DSP for a PMB condition.
Unfortunately there is a growing trend of providers ‘milking’ the PMB system, as they know that the medical schemes must theoretically pay their costs, even if such costs are much higher than the Medical Scheme Rates. Data from various medical schemes indicate that providers are starting to charge more for their services in the case of PMB conditions than for non-PMB conditions. The reality is that providing PMBs is costing medical schemes more and more each year, with the inevitable result of contributions having to be increased by more than usual. This is also why schemes are very strict in how PMBs are covered – should a member simply be able to claim the most expensive medicine for a given PMB condition, costs will soar out of control and medical schemes will either have to charge exorbitant contributions or no longer be financially sustainable.