Prescribed Minimum BenefitsWhat are prescribed minimum benefits (PMBs)?Prescribed minimum benefits are provided for in the Medical Schemes Act (Act No 131 of 1998). In terms of the Act, medical schemes are required to cover major medical treatment (typically in-hospital treatment) for certain conditions as defined in regulations of the Act. Prescribed minimum benefitsThe cover for PMBs is 100% of costs for diagnosis, treatment and care. Please note the following conditions: - There is no benefit limit, provided that services are rendered by Public Hospitals and/or designated service providers (see below).
- If you choose not to use a designated service provider, the PMB becomes subject to the normal benefit limitations and you may have to make a co-payment.
- If a benefit that is also defined as a PMB becomes exhausted, you will have to use a designated service provider.
- The Society will pay 100% of the cost if you involuntarily receive treatment and care for a PMB condition from a non-designated service provider in the following circumstances:
- The service was not available from the designated service provide or would not be provided without unreasonable delay;
- Immediate medical or surgical treatment for a prescribed minimum benefit condition was necessary under circumstances or at locations where it was not practically possible to get this treatment from a designated service provider; or
- There was no designated service provider within reasonable distance from your home or workplace.
In view of the above, and notwithstanding any other provisions in the rules, the Society will cover in full the diagnosis, medical management and medication for prescribed chronic conditions (PMBs) to the extent that this is provided for by way of a therapeutic algorithm* for a specified condition, as published by the Minister of Health by notice in the Government Gazette. * A therapeutic algorithm refers to the package of minimum benefits, e.g. tests, procedures, treatment and medication, appropriate to a specified prescribed chronic condition. This means that although PMBs are fully covered covered by law, this cover is not unlimited. For example, should you suffer from asthma, you will not have an unlimited choice of medication - the therapeutic algorithm will determine which appropriate medication you are entitled to. Designated service providerThe Society designates the following service providers for the delivery of PMBs to members: - All public hospitals
- Chronicare Medicines
- ER 24
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