Dear Business Partner,
In this edition, I will be looking at the Prescribed Minimum Benefits (PMB) – governed by regulations under the Medical Schemes Act (MSA) – and how this correlates with the need for gap cover.
The PMB are defined by pairs of diagnosis and treatment codes, covering around 270 conditions/procedures for mainly in-hospital treatment, plus 27 chronic conditions. The regulations oblige medical schemes to pay the full cost of treatment for PMB, although there are several criteria that need to be fulfilled before they are liable to do so. It is also important to note that not all medical treatment qualifies as PMB.
Over the past decade, the evolving patterns of charges from medical providers and the utilisation of medical services, have had a large impact on consumers. This is because the unavoidable response from medical schemes, in an effort to keep contribution increases as low as possible, has been to effectively reduce cover levels or impose co-payments through benefit design changes.
Obviously, where a medical scheme makes any change to their benefit design it must adhere to the PMB. So, I will take a look at the PMB and their associated rules and discuss why it is important to consider.
When is a PMB a PMB?
The policy principle of the PMB and the regulations is to financially protect members against large out-of-pocket medical costs.
However, to mitigate risks for medical schemes, the regulations obligate members to obtain treatment from one of their medical scheme’s Designated Service Providers (DSP), before PMB treatment costs must be paid in full.
In practice a DSP may not always be readily accessible, so the regulations also stipulate that if a member was compelled, through no fault of their own, to involuntarily obtain the services of a provider that is not a DSP for a PMB condition, then such treatment must still be covered in full by the medical scheme. If the treatment received meets any one of these three criteria, then treatment is deemed to have been obtained involuntarily:
- No DSP was available to provide the services, or could only be provided after an unreasonable delay
- Immediate treatment was required under circumstances or locations that reasonably precluded the member from obtaining such treatment from a DSP
- No DSP was available within a reasonable proximity to the member’s workplace or residence
Lastly, any treatment that is considered an ‘Emergency Condition’ is also a PMB. This is defined as any condition requiring immediate medical treatment that would otherwise cause serious impairment to bodily functions, an organ or body part or place the person’s life in jeopardy.
Below I have put together a simple decision tree to illustrate when a medical scheme is obliged to pay for PMB claims at cost and when it is not: