Prescribed minimum benefits
Prescribed minimum benefits (PMB) are a list of minimum benefits that all medical schemes must provide to members, irrespective of what benefit option they belong to.
PMBs are made up as follows:
Any emergency medical condition, such as a heart attack or motor vehicle accident which without immediate treatment would result in weakened bodily functions, serious and lasting damage to organs or limbs or even death;
270 medical conditions, for example childbirth;
25 defined chronic conditions, such as diabetes or asthma
Not all medical schemes openly disclose what you are entitled to.
For instance, if you have one of the 25 listed chronic conditions, your medical scheme not only has to cover the medication for that condition, they must also cover doctor consultations and prescribed tests related to that condition.
Speak to your healthcare consultant to understand what treatment you’re entitled to have covered.
All medical schemes must cover PMBs in full as regulated by the Council of Medical Schemes.
However, to contain the cost of providing this benefit, medical schemes may put measures in place to ensure you have the cover you need, without placing the scheme at financial risk by setting official procedures for certain treatments; enforcing the use of medication from a prescribed medicine list; and having designated service providers and hospital networks in place for treating and managing PMBs.
Medical schemes can impose important interventions and restrictions:
Co-payments (upfront payments) for using another service provider or medication not on the prescribed medicine list;
Waiting periods that include PMBs if a member has a break in medical aid cover of over 90 days or where a member has never belonged to a medical scheme before;
Penalties for going outside their network arrangement or failure to pre-authorise treatment or hospitalisation.
If you don’t abide by these, you face having to pay all or part of the cost of the treatment yourself.
Speak to your healthcare advisor or consultant if your hospitalisation, treatment or chronic condition medication, or test falls within the scope of a PMB but hasn’t been funded correctly or from the correct benefit.