Prescribed Minimum benefits: The Consumer Version

Timmy has fallen downstairs and is holding his arm and screaming! Panic stricken, the neighbour puts him and his frantic mother in the car and makes a furious dash to the nearest emergency room. After all this is an emergency, the medical scheme will cover it!  At the hospital the sobbing Mother is forced to put the treatment cost on her overloaded credit card which promptly refuses payment.

Do they have the most useless medical scheme in the country?

The answer is no, they simply do not legally have a claim if they are on a hospital plan or if they have run out of medical savings.

Now what would happen at the same hospital, same scheme and same neighbour- but this time it is Thabo who has fallen down the same stairs. Thabo has a bone poking out of his arm and blood pouring out the wound? His parents have run out of medical savings.

The hospital uses the correct protocols and is designated service provider for the medical scheme. This means Thabo’s treatment and surgery to set his arm will be paid for by the medical scheme. Thabo will also receive the same treatment if the family had exhausted their day to day cover on a traditional plan, or if they were on a hospital plan.

Confused? It is easy to be confused since Medical Schemes are not simple to understand. Prescribed Minimum Benefits or PMBs are one of the main areas for the medical scheme and member to end up in an unpleasant situation.

So let us look at why we have this term Prescribed Minimum Benefits or PMBs as most people call it?

In the 1990s government and consumer bodies agreed that medical schemes were not all created equal and needed to be changed. Certain beneficiaries of medical schemes would run out of benefits and find themselves forced to go to State hospitals for treatment. This was not what the Government wanted since the state hospitals were and still are under serious pressure.

It was agreed that minimum standards for medical schemes needed to be in place, so in January 2000 PMBs became the minimum consumer right for all medical scheme members.

In terms of the legislation all medical schemes would have to cover around 270 conditions, such as meningitis, various (but not all) cancers, menopausal management, cardiac treatment and many others, including medical emergencies. The PMBs also cover 25 of the most common life threatening diseases which are known as chronic diseases. There are no exclusions which can be applied to this level of care and your medical scheme may not refuse to pay for this basic treatment. This means the scheme cannot take this cost from your medical savings account or refuse to pay when your benefits have run out. However there are some limitations to this or all medical schemes would be too expensive to afford!   Medical schemes pay for the diagnosis, treatment and care of these diseases, but does not have to pay for any tests done to prove you have a PMB condition, if it is found that you don’t in fact suffer from one after the tests. This may lead to a nasty bill which you may have to pay.   The scheme is allowed to enter into agreements with medical service providers called designated service providers (DSPs) and put in a managed care protocol for use with these PMBs, which members must use or they can incur co-payments. The scheme may also insist on pre-authorisation for treatment of PMBs.   So what are these treatments?

The minimum treatments that have to be used are listed in a table called the diagnosis and treatment pairs or DTPS. This table has the disease or disorder matched to the treatment you should get in a public hospital called the prescribed minimum treatment. The treatment may be less than what your medical provider recommends for you, which then leads to a co-payment.

Some medical schemes have increased their treatment plans by entering into agreements with other medical service providers, such as treating a condition at a Netcare hospital, which is normally more expensive than a public hospital. This is at the scheme’s own discretion. Managed care contracts are entered into with designated service providers to give the scheme cost effectiveness and the member benefits, by cheaper premiums or a higher level of care than what is prescribed by a public hospital.

PMB diagnosis, treatment and care are not just limited to hospitals though. Treatment can be received wherever it is most appropriate, including a clinic, outpatient setting or even at home.

Medical schemes can make payment of a PMB benefit conditional on you obtaining pre-authorisation or joining a benefit management programme. These programmes are aimed at educating members about the nature of their disease and equipping them to manage it in a way that keeps them as healthy as possible in a cost effective manner.

What would comprise an emergency treatment?

Back to our examples.

Timmy has not got an emergency, as his life and arm are not in any danger, although his parents would not agree with that statement!

Thabo is in danger, with a severe break of his arm that will cause permanent damage if it is not seen to. This is because deformity and sepsis could result from the injury.

When it comes to an emergency it does not matter what the cause is. An emergency  is considered a sudden situation in which there is danger to life or to the body that will not be reversible unless medical or surgical treatment is immediately given.

Your doctor should know and understand most of the guidelines and you should ask them to help you get the treatment you need for any of these conditions without incurring costs that your scheme does not cover.