PMB

The Council for Medical Schemes has issued a Prescribed Minimum Benefits (PMB) consumer guide

Please read through the guide to ensure you have a better understanding of what PMB's entail.
Click here to view the guide.

What are Prescribed Minimum Benefits (PMBs) and how do they work?

PMBs were introduced into the Medical Schemes Act to ensure that members of medical schemes would not run out of benefits for certain prescribed conditions. These PMBs cover a wide range of close to 270 conditions that medical schemes must cover (according to set protocols), including but not limited to medical emergencies. Although PMBs must be funded in full by medical schemes, the Medical Schemes Act does allow schemes to use certain measures to manage the financial risk associated with the unpredictable health needs of their members. It is extremely important that you understand the implications of these measures so that you do not end up facing co-payments.

How can I make sense of PMBs?

To understand the impact of the legislation changes, it helps to understand the terms that are generally used when talking about PMBs.

PMB terms worth knowing

Prescribed Minimum Benefits (PMBs)

PMB's are minimum benefits which by law must be provided to all medical scheme members and include the provision of diagnosis, treatment and care costs for:

any emergency medical condition as defined
a set of approximately 270 medical conditions (called the Diagnosis and Treatment Pairs or DTPs* [see below], listed in the Regulations to the Act); and
the Chronic Disease List (26 chronic conditions including HIV and AIDS)

*DTPs - Certain conditions cannot be classified as a PMB condition on their own. To be classified as a PMB condition, the condition should manifest with another condition in a specific pre-defined way and it should be treated in a specific way in accordance with set protocols. This is known as Diagnosis and Treatment Pairs (DTPs). Only when all the DTP criteria are met will claims for the treatment of the relevant condition be classified as a PMB.

Designated Service Provider (DSP)

This refers to health care provider/s that have been selected by the Society to provide its members with diagnosis, treatment and care in respect of one or more of the PMB condition". The Society’s DSPs are:

All public hospitals
Clicks directmedicines (as well as the Healthcare Pharmacy in Kimberley, Lime Acres Pharmacy, Premier Mine Hospital Dispensary in Cullinan, the Namaqualand Pharmacy in Springbok and Dr HA Burger in Springbok)
ER 24 – Emergency Transport Service provider
ICON – Independent Clinical Oncology Network (Pty) Ltd. All oncology related consultation and treatment benefits will be subject to the ICON DSP and members are reminded that all oncology medication must be obtained from CDM. Should a non-DSP provider be used, a member co-payment of 25% of the consultation cost will apply,

In order to receive PMB benefits, these DSPs must be used otherwise co-payments as per the Society’s benefit structure will apply.

Please note that the Medi-Clinic hospitals listed on the Society’s list of Network Hospitals are Preferred Providers and not DSPs.

Emergency medical condition defined:

This is a medical condition which is of sudden and unexpected onset that requires immediate medical or surgical treatment, where failure to provide this treatment would result in impairment of bodily functions, serious dysfunction of a bodily organ or part, or would place the person's life in serious jeopardy.

Co-payment

A co-payment is the amount of money or the portion of the account that the Society may require you to pay from your own pocket. This could be either a percentage of the fee or the difference between the tariff of the Society’s DSP and the amount charged by the service provider (non-DSP) that attended to you.

What is Involuntary use of a non-DSP?

If circumstances force you to obtain a medical service from a non-DSP (i.e. involuntarily as is the case of an emergency medical condition), and it is a PMB condition, the Society will pay for the costs of your treatment, diagnosis and care in full. This may occur when:

· the required service is not readily available from the list of DSPs listed above,

· an emergency medical condition as defined above occurs, or

· there is no DSP within reasonable proximity to your place of residence or work.

If however, a beneficiary voluntarily obtains a diagnosis, treatment and/or care in respect of PMBs from a provider other than a DSP, the benefit payable in respect of such service is subject to such benefit limitations as are normally applicable in terms of the Rules of the Society and shall not exceed the benefit that would have been available had the DSP been used.

Why does the Society need ICD-10 codes to be reflected on your claim?

ICD-10 codes provide accurate and specific information on the condition that you have been diagnosed with and treated for and should be provided by your service provider on the account rendered for the service provided. These codes help the Society to determine what benefits you are entitled to receive and how these benefits must be paid. This becomes very important when you have a PMB condition as the code allows the Society to accurately identify the PMB condition. If the PMB condition is treated by one of the DSPs listed above, the account must be paid for in full by the Society with no member co-payments. ICD-10 codes therefore ensure that the correct benefit allocation is made.

Where can I obtain more information about PMBs?

Should you require more information regarding the PMBs or wish to register to receive PMB benefits, please contact the Society’s Hospital Utilisation Management Department on tel 053 807 3444 or e-mail managedcare@dbbs.co.za. Members can also access the Council for Medical Scheme’s website (www.medicalschemes.com) for regular publications and updates on this subject. A link to the Council’s website is also available on the Society’s website (www.dbbs.co.za)

Members are encouraged to familiarise themselves with the PMBs by reading all relevant information made available to them.