Few medical scheme members realise that they have access to certain minimum health services, regardless of the benefit option they have selected. The Medical Schemes Act No. 131 of 1998 and associated regulations were promulgated with the intention to provide people with continuous care to improve their health and well-being and to make healthcare more affordable.
Prescribed Minimum Benefits (PMBs) are a feature of the Act, in terms of which medical schemes must cover the costs related to the diagnosis, treatment and care of:
Any emergency medical condition;
• a limited set of 270 medical conditions (defined in the Diagnosis Treatment Pairs)
• and 25 chronic conditions (defined in the Chronic Disease List).
Many medical aid beneficiaries are unaware that these acute, chronic and emergency medical conditions and illnesses are covered by their scheme even if they are on a hospital cover option. According to the Independent Community Pharmacy Association (ICPA) medical scheme individuals may be paying for medical treatments out of their pockets when in fact the medical scheme would pay if the invoice was submitted with the correct diagnostic information.
Conditions you should be covered for – regardless of your medical plan
For most South Africans medical aid coverage is a large expense in their monthly budget. Because of this, many people opt for an entry level plan or a basic hospital plan. The general understanding of “cheaper” medical scheme options and hospital plans is that they cover only a small portion of hospital medical expenses incurred and there are many exclusions. Some members may have a savings account which will pay for some of the out of hospital medical bills and most have a prescribed network of doctors, hospitals and other healthcare providers that they must use. What they don’t realise is that there is an extensive list of acute medical conditions that must be covered by a medical scheme – regardless of whether the member is on an entry level plan, a hospital plan or a comprehensive policy. Benefits for PMB conditions on a “hospital plan” do not require hospitalisation in order for the member to be covered, subject to schemes’ rules.
“It would probably surprise people to realise that illnesses/conditions such as croup, whooping cough, asthma attacks, middle ear infections (Otitis Media) and Herpes (both Zoster and Simplex) are covered under the list of PMB’s and costs incurred in the treatment of these must be covered by your medical aid scheme – regardless of what plan you are on,” says Jackie Maimin, CEO of ICPA.
Other examples of illnesses or medical conditions that may not necessarily require hospitalised treatment, but which are still PMB’s that must be covered by medical schemes, are: rheumatic fever; fractured and dislocated limbs; the removal of a foreign body in the ear or nose; the diagnosis and treatment of TB; and hereditary anaemia such as sickle cell anaemia.
Voluntary counselling and treatment for HIV infection, as well as preventative therapy, treatment of opportunistic infections, post-exposure prophylaxis and the provision of anti-retroviral therapy are all covered under the list of PMB’s. Hospital-based management for abuse or dependence on psychoactive substances, including alcohol are covered up to 3 weeks/year. The management of menopause, including hormone replacement therapy, is another example of a condition on the list of PMB’s and consequently must be covered by the scheme.
According to the ICPA, medical schemes usually have a list of conditions – such as cosmetic surgery – that they will not pay. These are called exclusions. “However, exclusions do not apply to PMB’s and if, for example, you contracted septicaemia after cosmetic surgery your medical scheme would have to cover the medical costs for the treatment of the septicaemia as it is on the list of PMB’s.”
While medical aid schemes are obliged to fund the diagnosis and treatment of PMB conditions, schemes may exercise their rights to limit treatment to the PMB level of care the minimum level being that which is available in a State facility.
Closed DSP’s and emergencies
The ICPA goes on to advise that most of the lower option medical plans and hospital plans have a list of prescribed medical practitioners, suppliers and hospitals that you must use – called Designated Service Providers (DSP’s). Should you opt to voluntarily use one outside the prescribed list, the medical scheme may cover the full cost of the treatment and you may be charged a penalty co-payment. This will not be the case if you use a non-DSP in certain circumstances e.g. in an emergency.
“When you suffer an emergency condition, or are involved in an accident, you may go to the nearest healthcare facility for treatment, even if it is not a DSP. Your scheme will have to cover the costs,” advises Maimin.
Read the fine print
An entire code of conduct exists to regulate the management of PMB’s, with a revised version having been released in 2017. The purpose of the Code of Conduct is to protect the interests of beneficiaries of medical schemes regarding their entitlements and access to PMB’s.
“The Code of Conduct in respect of PMB’s states that medical schemes must inform their members about their access to these PMB benefits, and the use of DSP’s, when they join a scheme and at the start of each new year. However, very few of us take the time to read the small print when joining or renewing our medical coverage. Added to this is the fact that sometimes all of the information can be overwhelming to digest.”
“Because of this, many people are probably paying for medical treatment which should be covered by their scheme. Visit the Council of Medical Schemes website and equip yourself with the necessary knowledge – it could save you a lot of time, money and stress,” says Maimin. “Further good news is that the Code of Conduct calls for all communications to members in respect of their benefits to be clear and in plain language – this makes reading through the fine print a bit less onerous.”
“If you are unsure or require advice about your scheme options around PMB you can communicate with your independent community pharmacist or their staff who are always willing to assist to ensure you get the best possible outcomes” said Maimin. The ICPA will make resources available to help member pharmacies to provide the best possible advice on scheme issues for their patients.
The full list of 270 PMB’s is available as a downloadable spreadsheet on the Council For Medical Schemes website:
http://www.medicalschemes.com/medical_schemes_pmb/conditions_covered.htm
