Approximately 16% of South Africans currently use a medical aid to help pay for their health-related expenses. Medical aids are essentially private companies, but they do need to conform to government rules. One of these rules relates to what the medical aids MUST cover or pay for when the members of that fund need care. These needs or medical conditions are called Prescribed Minimum Benefits (PMBs). Knowing how to access this part of your medical aid benefit is an important way to help keep your medical expenses down.
What are Prescribed Minimum Benefits (PMBs)?
Prescribed Minimum Benefits (PMBs) 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. PMBs are a feature of the Medical Schemes Act, in terms of which medical schemes have to cover the costs related to the diagnosis, treatment and care.
Understanding PMBs
The benefit is only applicable when the diagnosis made by the treating healthcare provider is one of those included on the master list of conditions covered under this Act (diagnosis-based approach). There is a list of specified medical conditions, but all acute serious injuries are also covered. Your healthcare provider will assess both the condition and the cause of the condition. Once the diagnosis has been made, the appropriate treatment and care is decided upon, as well as where the patient should receive the treatment (at a hospital, as an outpatient or at a doctor’s rooms).
PMBs will be covered from your available day-to-day benefits first. If your benefits are depleted, the Scheme will continue to pay for PMBs above the benefits from the pooled risk fund. PMBs may not be covered from your Medical Savings Account.
How do I register a Prescribed Minimum Benefit condition?
There are different types of PMB cover. These include cover for: in-hospital admissions, conditions under the Chronic Disease List, out-of-hospital management of PMB conditions and treatment of PMB conditions such as oncology.
To apply for out-of-hospital PMBs, you or your healthcare provider must complete the Prescribed Minimum Benefit application form. PMB forms are usually available on the medical aid scheme website. We can assist you with this, but you will still need to give authorisation to us to do this, and will need to sign the application form.
Here is a brief outline of the process:
- Download the PMB forms from your medical aid scheme website.
- Complete the patient personal information details on the form, and have it signed by the patient/member.
- Give the form to your healthcare provider to sign.
- Email the fully completed form to the relevant Medical Aid and await correspondence from fund.