PMBs explained

PMBs often cause confusion among patients and medical practitioners.

This PMB Guide deals with the 25 chronic ailments. Prescribed Minimum Benefits 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. 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 of:

• Any emergency medical condition

• A limited set of 270 medical conditions (defined in the Diagnosis Treatment Pairs)

• 25 chronic conditions (defined in the Chronic Disease List).

When deciding whether a condition is a PMB, only look at the symptoms and not at any other factors, such as how the injury or condition was contracted. This approach is called diagnosis-based.

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). An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or an operation.

If the treatment is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death.

In an emergency it is not always possible to diagnose the condition before admitting the patient for treatment. However, if doctors suspect that the patient suffers from a condition that is covered by PMBs, the medical scheme has to approve treatment.

Schemes may request that the diagnosis be confirmed with supporting evidence within a reasonable period of time. Schemes must fund the diagnostic investigations up to the point where the diagnosis is confirmed. If a PMB is confirmed, the scheme must fund the treatment.

PMB review

The current PMB package is currently being reviewed. There have been complaints that it does not prioritise the needs of the country and the design doesn’t prioritise primary healthcare services. There are inconsistencies and flaws in the current regulations. The current package covers only emergency medical conditions, CDLs and a limited set of diagnosis and treatment pairs for certain medical conditions. There also needs to be consistency with developments in health policy.

Focus areas will be to document the relationship between the PMBs and the public healthcare system, specify a comprehensive set of essential healthcare benefits, and coding of the package to include clear diagnosis and procedure codes.

According to Acting Chief Executive and Registrar, Dr Sipho Kabane, there are different interpretations of how the PMBs are to be used, by patients, service providers, medical schemes and administrators. This creates disputes and serious problems of members not accessing the benefits that they are entitled to.

“Dr Aaron Motsoaledi gave the mandate that the PMBs need to reflect the disease burden of the country, such as HIV, TB, and non-communicable diseases. We need to make sure that there is a primary healthcare package attached.

“We will need to define the benefits much more clearly and do the costings. We would like to focus on primary healthcare in the PMBs and then tackle the bigger issue of what needs to be included and excluded.” he said.

The following applies to all 25 chronic conditions

1 Medical management reasonably necessary for the delivery of treatment described in this algorithm is included within this benefit, subject to the application of managed health care interventions by the relevant medical scheme.

2 To the extent that a medical scheme applies managed health care interventions in respect of this benefit, for example clinical protocols for diagnostics procedures or medical management, such interventions must –

• not be inconsistent with this algorithm;
• be developed on the basis of evidence-based medicine, taking into account considerations of cost-effectiveness and affordability; and
• comply with all other applicable regulations made in terms of the Medical Scheme Act, 131 of 1998

3 This algorithm may not necessarily always be clinically appropriate for the treatment of children. If this is the case, alternative paediatric clinical management is included within this benefit if it is supported by evidence-based medicine, taking into account considerations of cost-effectiveness and affordability.

*All chronic disease algorithms are as per the Medical Schemes Act, 131 of 1998.

PMB-X GUIDELINES 2019