Prescribed Minimum Benefits (PMBs) are a crucial component of South Africa’s healthcare system, ensuring that all medical scheme members have access to essential medical services for critical, chronic, and life-threatening conditions. Mandated by the Medical Schemes Act of 1998, PMBs provide a safety net for patients, guaranteeing coverage for specific diagnoses and treatments without additional out-of-pocket expenses. However, while PMBs offer significant advantages, such as immediate access to necessary care and protection against financial burdens, they also come with limitations, including restricted coverage scope and potential barriers to specialist access. This paper explores the definition, implementation, and management of PMBs, emphasizing their importance in maintaining healthcare equity and financial sustainability within the medical scheme landscape.
1. Introduction
1.1 What is Prescribed Minimum Benefit ?
Prescribed Minimum Benefits (PMBs) are a set of benefits that medical schemes in South Africa must provide to patients. These benefits are outlined in the Medical Schemes Act 131 of 1998 and its Regulations. To access these benefits, patients must meet certain conditions, which are classified as critical, chronic, or life-threatening, and their treatment must match the treatments in the defined benefits.
1.2 Overview of Prescribed Minimum Benefits
The Medical Schemes Act mandates that all registered medical schemes in South Africa provide Prescribed Minimum Benefits (PMB) for their members, regardless of their plan type. These benefits cover diagnosis, treatment, and care costs related to emergency medical conditions, 271 diagnoses, and 27 chronic conditions (Chronic Disease List conditions). To access PMB benefits, members must meet certain requirements, including qualifying for cover and being on the list of defined PMB conditions. They must send the Scheme results of their medical tests, provide correct documentation, and register on the scheme’s disease management programs.
Treatments must match the defined benefits on the PMB list, supported by evidence-based treatment guidelines. If there is no Designated Service Provider (DSP) applicable to their plan, they must use them. If not, they will pay up to 80% of the rate, and members are responsible for the difference between the paid amount and the actual treatment cost.
In emergencies, members can go directly to the hospital and notify the scheme of their admission. The scheme provides cover for the first 24 hours or until the patient becomes stable enough to transfer to a DSP. Benefits not included in the PMBs are paid for from available plan benefits, where appropriate, and according to the rules of their chosen health plan. To find healthcare providers, members can visit the website or the Discovery app, then register for PMBs and chronic disease list conditions.
2. Background
2.1 PMBs Unveiled: Essential Care with Hidden Limits!
Prescribed Minimum Benefits (PMBs) are essential healthcare services that ensure all medical aid members have access to necessary care for critical, chronic, or life-threatening conditions. They guarantee guaranteed coverage, allowing patients to receive necessary services without worrying about their medical scheme covering the cost. PMBs also provide immediate treatment, especially for critical and life-threatening conditions, where delays can have serious consequences. Medical schemes cannot charge co-payments or deductibles for PMB benefits, eliminating the need for patients to pay additional out-of-pocket expenses.
However, PMBs have limitations, such as limited coverage, limited scope of coverage, and limited access to specialists. PMBs only cover the diagnosis, treatment, and care of specific medical conditions included in the PMB list, and patients may still need to pay for other medical conditions or non-PMB medical services. If not necessary for the medical condition, some treatments or interventions may not be covered. Lastly, PMBs may limit access to specialists, as medical schemes are only required to cover the cost of treatment provided by a specialist in cases where it is necessary for the specific medical condition.
3. Analysis
3.1 PMBs: Your Safety Net for Essential Healthcare
PMBs were created to ensure continuous healthcare for medical scheme beneficiaries, even if their benefits have run out. They also ensure that healthcare is paid for by the correct parties, as members with PMB conditions are entitled to specified treatments that must be covered by their medical scheme, even if they were treated at a state hospital. PMBs also aim to provide minimum healthcare to everyone, regardless of their age, health status, or medical scheme cover option. They also play a role in maintaining the financial health of medical schemes by improving general wellness and reducing the cost of treating serious conditions.
3.2 How do I register for the Prescribed Minimum Benefit condition?
To register a Prescribed Minimum Benefit (PMB) condition, follow these steps:
- Consult Your Doctor: Ensure you receive an accurate diagnosis and the correct ICD-10 code from your doctor, as this is essential for PMB eligibility.
- Contact Your Medical Aid Scheme: Inform your medical aid provider about your PMB diagnosis.
- Submit necessary documentation: You may need to provide a completed application form, medical reports, or test results to support your diagnosis, depending on your scheme’s requirements.
- Check for Specific Requirements: Be aware that some schemes may have particular procedures for registering certain PMB conditions, including regular reviews or designated service providers.
- Important Points:
– For chronic PMB conditions, registration is typically a one-time process.
– Certain mental health conditions may require annual re-registration. - After registration, your medical aid scheme may provide a treatment plan detailing covered treatments and medications.
4. Implementation
4.1 Responsibilities of Healthcare Providers?
Healthcare providers typically do not have a direct contractual relationship with medical schemes, but they play a crucial role in the successful functioning of private medical plans (PMBs). To ensure payment, doctors should familiarize themselves with ICD-10 codes and their correspondence with PMB codes. They should also consider patients’ options and what can be realistically covered before recommending a drug or treatment. Patients should be alerted to their condition as a PMB and encouraged to engage in their medical scheme.
Proper clinical records should be maintained to justify alternative treatments when formulary drugs or protocols are not effective or cause adverse side effects. It is essential not to abuse PMBs, as it could lead to an unsustainable private healthcare system with unaffordable contribution increases. Additionally, doctors should allow their practice to be listed as a Direct Support Provider (DSP), as the “payment in full” concept ensures accessibility of healthcare services for medical scheme beneficiaries.
4.2 Managing PMB’s in Practice Management Software
Medical aid schemes provide prescribed minimum benefits for the applied patients. It provides an authorization number, number of sessions, and ICD-10 code for the patient with PMB. If a claim needs to be paid under PMB, then that invoice should contain the auth number and the ICD-10 code. smeMetrics practice management software helps healthcare providers in managing their PMB’s.
- Login to the software using credentials
- Select the contact, enable the “PMB ” option under the medical aid section, add the auth number, and click on save.
- If you generate an invoice , it automatically pulls all the details.
- If you have to add PMB details just for an invoice and not for the contact, then you can add it after generating an invoice.
- You can send that invoice to the scheme.
- If it’s paid, then you can see it on the medical aid remittance “paid from PMB.”.
- You can track it based on the number of invoices generated for that client after adding PMB.
- Please note: Schemes won’t pay once the PMB sessions are used up; you need to keep track of it by checking it with the schemes. The patient might have used some of the sessions with other practitioners.
5. Conclusion
In conclusion, prescribed minimum benefits serve as a vital mechanism to ensure that all South African medical scheme members receive necessary healthcare services, particularly for critical and chronic conditions. Even though PMBs protect people and make sure everyone has equal access to care, they have some problems that show they need to be constantly reviewed and maybe even changed to work better. By fostering a better understanding of PMBs among healthcare providers and patients alike and by utilizing efficient management systems, the healthcare community can ensure that these benefits fulfil their intended purpose, ultimately contributing to a healthier population and a more sustainable healthcare system.
To learn more about invoicing, please refer to our in-depth article below:
