What are PMBs?
The regulations published in terms of the Medical Schemes Act No. 131 of 1998 stipulate the scope and level of the minimum benefits to which members of the Scheme are entitled. 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 Plan they have selected.
PMBs are fully covered by your medical scheme, provided you follow the guidelines. The cover is related to the diagnosis, treatment and care of:
any emergency medical condition
a limited set of 270 Diagnostic Treatment Pairs (DTP) defined in the Regulations and published on the Council for Medical Schemes website
26 chronic conditions (defined in the Regulations and published under Which basic chronic conditions are covered by all Plans?
When deciding whether a condition is a PMB, the doctor should look only at the symptoms and not any other factors, such as how the injury or condition was contracted. This approach is called diagnosis-based. Once the diagnosis has been made, the appropriate treatment and care is decided upon, as well as where the patient should receive the treatment (at a hospital, as an outpatient or at a doctor’s rooms).
|PRESCRIBED MINIMUM BENEFITS|
|270 Diagnostic Treatment Pairs (DTP)||26 PMB Chronic Conditions|
|Acute Conditions||Chronic Conditions||Hospitalisation||Medical management of the condition||Medicine for the condition|
|Medical management of the condition||Medicine management of the condition||Medical management of the condition||Medicine for the condition|
Why do we have PMBs?
There are two reasons why PMBs are in place:
- To ensure that medical scheme beneficiaries have continuous cover for PMB related conditions. This means that even if a member’s benefits for the year run out, the Scheme will continue to pay for the treatment of PMB conditions. These benefits are subject to the medical management treatment protocols.
- To ensure that healthcare is paid for by the correct parties. Medical Scheme members with PMB conditions are treated according to the specified treatments and these have to be covered by their medical scheme, irrespective of where the patient is treated.
Which PMB conditions are covered by the Scheme?
Emergency Medical Conditions
An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or an operation. If the treatment is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death.
In an emergency it is not always possible to diagnose the condition before admitting the patient for treatment. However, if a doctor suspects that the patient is suffering from a condition which is covered in terms of PMB, the Scheme is required to approve the treatment. Schemes may request that the diagnosis be confirmed by supplying supporting evidence within a reasonable period of time.
Diagnostic Treatment Pairs (270 medical conditions)
The Regulations to the Medical Schemes Act provide a long list of conditions identified as PMB. The list is in the form of Diagnosis and Treatment Pairs (DTP). A DTP links a specific diagnosis to a treatment and therefore broadly indicates how each of the approximately 270 PMB conditions should be treated.
Here is an example of a DTP as it appears in the Medical Schemes Act:
|109A||Vertebral dislocation/fracture, open or closed with injury to spinal cord||Repair/reconstruction; medical management; in-patient rehabilitation up to two months|
If your PMB condition is not an emergency or a PMB chronic condition, but is a once-off PMB condition as diagnosed by your doctor, you will be covered as per the Scheme Rules. If you are unsure of whether your diagnosed acute condition is covered as a PMB you can contact the Scheme to clarify this. The administrator will require the ICD10 code to determine whether the condition is an acute PMB condition.
Once the condition has been identified as an acute PMB condition, the administrator will request that you submit your claim/s, together with the ICD10 code, relevant tariff codes, doctor’s practice number and any test results (including pathology and radiology) that support the diagnosis.
To avoid PMB claims being rejected
- Check that your doctor/service provider has included the correct ICD10 code on your account.
- ICD10 codes provide accurate information on your diagnosis and this assists in determining which benefits you are entitled to and how these benefits could be paid.
- Your PMB condition will be identified by the ICD10 code, so if the incorrect code is used, your PMB-related condition will be paid from the wrong benefit.
- ICD10 codes must also be provided on medicine prescriptions and referral notes to other healthcare providers.
If your PMB claim is rejected
You can contact the Scheme at 0860 100 080 to enquire about the reason for the rejection and process to follow. It is important to check that your practitioner has put the correct ICD 10 and tariff codes on your invoice.
The Scheme is obliged by law to treat information about members’ conditions with the utmost confidentiality. No information pertaining to a member’s condition will be disclosed to any other party, including the member’s employer or family.
Who are the Scheme's Designated Service Providers for PMBs?
GP or specialist visits
If you are diagnosed with a PMB condition, it would be to your benefit to make use of the general practitioner or specialist on the Nedgroup GP and specialist network for your medical management where general practitioner or specialist visits are clinically indicated for the condition. If you choose a GP or specialist on the Nedgroup GP and specialist network, your PMB-related account will be paid from the PMB benefit at a Scheme-agreed rate, and you will not be liable for any co-payment on your specialist’s claim should you be admitted to hospital. (In the case of members on the Platinum Plan, no co-payment will apply if a non-Network provider is used. However, bear in mind that your hospital-related claims will only be paid at Medical Scheme Rates and that you will be liable for the difference.)
Alternatively, you may wish to continue consulting your own practitioner, even if he/she is not part of the network. In such a case the service provider will be covered at Medical Scheme Rate, and paid from your available Everyday Services Benefits (except on the Hospital Plan, which does not have Everyday Services Benefits). Thereafter the service will be covered from the PMB benefit for all Plans, with a co-payment of 25% that you will need to cover from your own pocket.
The consultant will confirm whether the practitioner is part of the Nedgroup GP and Specialist Network, or provide details of practitioners on the network.
Nedgroup Network Pharmacies is the Designated Service Provider (DSP) Pharmacy network for chronic medicine. Members who voluntarily use a non-designated pharmacy service provider for their approved PMB medication, will be liable for a 25% co-payment at the point of sale at the pharmacy. In other words, the Scheme will only pay 75% of the claim for the approved/authorised medication.
Members who use a non-DSP pharmacy provider for their chronic medicine (the additional 21 conditions which fall outside of the 26 PMB conditions), will have their account paid from their available Everyday Services Benefits. Once the Everyday Services Benefits are depleted, you will be liable for the full account at point of sale at the pharmacy. Chronic medicines will only be paid from your chronic medicine benefit if obtained from a Nedgroup Network pharmacy.
Further to this, the Regulations stipulate that a member’s personal medical savings account (for Savings Plan members only) may not be used to fund any co-payment costs related to PMB claims. Members must therefore settle the co-payment directly with the service provider.
To apply for authorisation for chronic medicines, please contact ScriptPharm Risk Management on 011 100 7557 Monday to Friday, 08:00 – 16:30 or fax the application form to 0866 791 579 or email nedgroup at scriptpharm.co.za
The hospital that your doctor refers you to is the DSP for hospitalisation.
How do I register on the PMB Medical Management Programme?
Please have the following information readily available before calling:
- Name of member
- Name of beneficiary applying for benefits
- Membership number
- Date of birth or identity number (for member registering on the programme)
- Treating doctor’s name and practice number
- Condition to be covered – ICD10 code to be supplied by treating doctor
- Whether you are already registered as a chronic medicine user
If your condition requires basic primary healthcare treatment and/or diagnostic tests, you will be informed of your PMB treatment plan, in writing, once it has been authorised. This communication is triggered if the correct ICD10 and tariff codes are submitted on the claim.
Treatment Plans for members registered for conditions on the PMB Chronic conditions list (in the Chronic Benefits chapter) will roll over each year and members do not have to re-apply. Members who had a Treatment Plan for any condition that is not on the PMB Chronic conditions list mentioned above must please note that such a Treatment Plan will generally not roll over from one year to the next, and they would have to reapply, if necessary. In either case, Treatment Plans may differ from those of the previous year.
Prescribed Minimum Benefits - How can they benefit you?
Many members and even healthcare providers still don’t understand how 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.
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.
THE ‘DARK SIDE’ OF PMBS
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.