Empower Yourself With Knowledge Of Prescribed Minimum Benefits

The first time you hear the words from your physician to confirm your diagnosis your emotions go into overdrive often leading to short or long term depression. There are so many implications to your life and the lives of those around you – how will you cope emotionally, physically? But then you think “at least I have a Medical Scheme that will support me and cover any legitimate costs related to my treatment.“

You have, after all, fulfilled your part of the deal by paying your monthly contribution and now it is time for your medical fund to fulfil their part of the deal as you have been diagnosed with a disease on the PMB, Prescribed Minimum Benefit list. But, it is this precise assumption that can lead to treatment not being covered and additional strain in your life. It is the responsibility of Medical Scheme members to empower themselves through knowledge and to know their rights.

PMBs form part of the Medical Schemes Act (1998) and implementation of the treatment of PMBs is regulated by government. According to the Council for Medical Schemes: PMB’s are a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. The aim is to provide people with continuous care to improve their health and well-being and to make healthcare more affordable.

Schemes therefore have to cover the diagnosis, treatment and care of:

• any emergency medical condition;

• 270 medical conditions as defined in the Diagnosis Treatment Pairs

• 25 chronic conditions defined in the Chronic Disease List

Not all medical conditions have clear and legislated treatment plans. Members need to source as much information as possible about the treatment of your condition from your physician (your Designated Service Provider), as well as the medical scheme’s rules and listed medication and treatment for your specific condition. Your medical scheme will not always ensure that treatment is covered unless YOU keep careful track of your claiming process.

General conditions for PMB’s:

• Costs related to diagnosis, treatment and care of PMB’s are not allowed to be passed through your medical savings account or your day-to-day expense plans.

• The medical schemes are allowed to stipulate DSPs, Designated Service Providers, but they have to be within a reasonable distance of your work and home.

• Treatment at a DSP will be covered in full by the medical scheme under the PMB conditions when delivered according to scheme protocols and procedures.

• Medical Schemes cannot charge a co-payment or levy for the treatment of a PMB if you have followed the scheme’s protocols.

See part two of this article written by the new National Chairperson of Multiple Sclerosis SA, Dr Samantha Gregory, in the Jan/Feb 2011 issue of Rolling Inspiration!

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