As a medical aid member do you enjoy exactly the same benefits as your fellow scheme member?
The answer is No! My guess is that you knew that already. Those members with more bucks pay bigger premiums and enjoy better benefits. Those scheme members with fewer bucks – well let’s just say their coverage isn’t as comprehensive. You get what you pay for right?
“But there is something horribly unfair about that”, I hear you mutter. “Shouldn’t all scheme members enjoy a certain level of coverage? I mean regardless of your medical aid plan type, shouldn’t medical schemes be picking up certain costs in full?”
Let me introduce you to a new term. PMB.
PMB stands for “Prescribed Minimum Benefits“. Simply put, its a list of conditions your medical scheme needs to pay in full regardless of the plan type you are on. Now without boring you to death with a ton of detail this is what you really need to know about PMBs. Take note.
1. It’s law. Your medical scheme needs to pay for PMB conditions in full. “Why is that?” The Regulations of the Medical Schemes Act of 1998 clearly state:
“Prescribed Minimum Benefits – (1) Subject to the provisions of this regulation, any benefit option that is offered by a medical scheme must pay in full, without co-payment or the use of deductibles, the diagnosis, treatment and care costs of the prescribed minimum benefit conditions.”
2. “What’s covered in the PMB list?”
Any emergency medical condition
270 medical conditions
25 chronic conditions
3. Your medical scheme might be forced to pay the PMB’s in full but they can ask you to tow the line. You see, because no medical aid scheme can afford to simply open themselves up to limitless pay-outs they need to be offered a little room to move. The law had to provide options to medical schemes to ensure the costs remained manageable. So your medical scheme are within their rights to:
3.1 Appoint Designated Services Providers
3. 2 Have Formularies (medicine lists) & treatment plans in place
Your scheme has to pick up the cost of you PMB’s in full but they will ask you to use a designated service provider. If you chose not to use a DSP, your scheme can (and will) hit you with a co-payment. Your medical scheme is also allowed to have their own treatment protocols In place to handle PMBs. All that means is that your scheme can choose how to treat your PMB condition.
One last tip – when you pre-authorize any procedure with your medical scheme, check if the condition or procedure is a PMB condition. Let’s just say I’ve had clients who were only made aware after the fact that their condition was a PMB, didn’t get the option of using a DSP and ended up coughing up unnecessary money. Just something to remember!
* For more money matters check out: http://www.insurancefundi.co.za