All medical schemes have to provide certain benefits to you regardless of the option to which you belong.
These benefits must cover in full the costs of the diagnosis, treatment and care of certain conditions regardless of what the provider charges. These are known as the prescribed minimum benefits (PMBs).
The PMBs ensure that you always have some essential cover – but there are some gaps in the conditions covered and for this reason the PMB benefits have been under review for some time.
Currently, the PMBs cover:
The 271 conditions can be difficult to identify, so make sure you always ask your doctor if the condition is a PMB. You can also ask your doctor to give you what are known as the ICD10 codes for your diagnosis.
You can then check on this list if the condition is a PMB or contact the Council for Medical Schemes.
Ensuring your claim is paid as a PMB
Medical schemes are obliged to pay your PMB claims in full, but they also have the right to try to limit their costs.
Your scheme may therefore:
1. Appoint a provider
Your scheme can appoint a particular healthcare provider and insist you use that provider for the treatment of a PMB condition. This provider is known as a designated service provider (DSP).
Make sure you know who the provider is for your condition – they should be named in the rules of the scheme and your scheme should inform you who the provider is if you ask.
A scheme can appoint the state as the DSP for one or more of the PMBs, but if it does, the Council for Medical Schemes is of the view that the scheme must have a contract with the state to ensure that you will be treated.
The Registrar for Medical Schemes, who is also the chief executive of the Council for Medical Schemes, requires schemes that contract with the state to demonstrate that they have assessed the state as a provider able to provide the relevant services.
If you do not use the DSP, the scheme may impose a co-payment. The co-payment could be a set amount or equal the difference between the actual charge and what the designated service provider would have charged. The amount or formula used to determine the co-payment should be defined in the rules.
The Council for Medical Schemes has stated that the co-payment cannot be the full amount you were charged.
There are also some instances when your medical scheme cannot impose a co-payment. These cover cases where you need to use a provider other than the DSP named by your scheme because:
If you are treated by a non-DSP hospital in an emergency, you may where appropriate, be transferred to a DSP hospital or facility once your condition has stabilised.
2. Draw up treatment protocols
Your scheme may draw up a treatment plan – known as treatment protocols – that you need to follow in 
order to have your PMB claims covered in full.
If your scheme has a treatment plan it:
If the treatment your doctor recommends is beyond that outlined in the treatment guidelines, your doctor can still ask the scheme to approve it and motivate why you need that treatment.
Your scheme may insist you try the guideline treatment first.
If you are denied cover, you have the right to appeal the decision to the Registrar of Medical Schemes. The registrar’s office will also consider the merits of your case.
3. Insist you use certain medicines
Your scheme may specify the medicines that should be prescribed for your PMB condition. These will be listed 
on your scheme’s medicine list or medicine formulary. They will typically include cheaper generic medicines rather than brand name ones.
However, if a medicine or treatment is not suitable for you – for example, you have an adverse reaction or it proves to be ineffective, a regulation under the Act provides for you and your doctor to ask your scheme to approve an alternative treatment.
4. Ask you to join the programme
Medical schemes are entitled to contain their costs by requiring you to get pre-authorisation for your treatment or to join the scheme’s disease management programme. Schemes offer such programmes, for diseases such as diabetes.
Disease management programmes aim to educate you about your disease and the treatment you require.
Refusing to sign up for such a programme is likely to make it difficult for you to get your benefits, but the Council for Medical Schemes has noted in one of its annual reports some years ago that you cannot be denied PMB benefits if you fail to register on such a programme.
Paying PMB claims
Your medical scheme should identify a condition as a PMB one from the ICD10 codes and pay it from what is 
known as your medical scheme risk benefits. This means the claim should not be paid from your medical savings account.
There may, however, be times when your scheme requires more information before it will pay your claim in full as a PMB claim.
You may also need to register for your scheme’s chronic medicine benefit or disease management programme in order to access the benefits.
It is therefore worth checking your claims to ensure they are dealt with correctly and if not, approach your scheme to find out why.
When you are not covered by the PMBs
If you join a medical scheme for the first time, without having been a member previously or after a break in membership of more than 90 days, you may be subject to a three-month waiting period, during which time you and your dependants will not have access to the PMBs.
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DID YOU KNOW?
In 2020, the average cost paid by all schemes to provide the PMBs was R866 per beneficiary (members and dependants) per month, according to the Council for Medical Schemes. Schemes have argued that the open-ended liability for PMBs is untenable and the regulation stating that schemes must pay these benefits in full has been the subject of a number of legal challenges and draft legislation. In 2019, the Competition Commission’s Health Market Inquiry recommended that a Supply Side Regulator be established and operate a negotiating forum for all practitioners to set a maximum price for the PMBs and reference prices for non-PMB health services. There have been no further developments on any of the commission’s proposals. |
The cost to your scheme of providing the prescribed minimum benefits to all members makes up around 50% of the cost of your medical scheme contributions. The average cost of providing these benefits is cheaper on schemes with younger, healthier members and older members typically use more PMB benefits than younger members.