Prescribed Minimum Benefits (PMBs) For Medical Aids

Prescribed minimum benefits are list of conditions and treatments that a medical aid has to cover for every member on its scheme, irrespective of the individual plan or availability of funds for that year. Basically prescribed minimum benefits are an assurance that every member will have medical aid cover when they need it the most. It comprises any medical emergency, diagnosis and treatment for some 270 medical conditions and full treatment and management of 25 chronic conditions. This required benefit is now part of the Medical Schemes Act  and a medical aid may therefore not refuse to pay for at least minimum services for these conditions.

A Simple Explanation of Prescribed Minimum Benefits

A medical aid has separate benefits for in-hospital, out-of-hospital (day-to-day) and chronic conditions. A member on a hospital medical aid plan would not have the out-of-hospital benefit. In the past, if a medical aid member exhausted all the funds of any of these benefits, he/she would have to either pay out of their own pocket, wait till the next year or utilise public health services. This meant that patients were being refused funding, treatment and medical care in the private health sector for sometimes life-threatening conditions once the funds for the year were exhausted and if they could not afford it.

The amendment to the Medical Schemes act brought about the prescribed minimum benefits which all medical aid members have access to within limits. This means that even if a member’s funds for the year was exhausted or that his/her specific plan did not traditionally cover these benefits, the medical aid member could now access minimum health services for the prescribed benefits. This may include the diagnosis, treatment and management of :

  • any emergency medical condition
  • 270 medical conditions
  • 25 chronic conditions

The prescribed minimum benefit (PMB) was implemented to protect all medical aid members.

Prescribed Medical Benefits (PMBs) for Chronic Conditions

A list of 25 chronic conditions are covered as a prescribed minimum benefit and this includes :

  • Addison’s disease
  • Asthma
  • Bronchiectasis
  • Cardiac failure
  • Cardiomyopathy
  • Chronic obstructive pulmonary disorder
  • Chronic renal disease
  • Coronary artery disease
  • Crohn’s disease
  • Diabetes insipidus
  • Diabetes mellitus types 1 & 2
  • Dysrhythmias
  • Epilepsy
  • Glaucoma
  • Haemophilia
  • Hyperlipidaemia
  • Hypertension
  • Hypothyroidism
  • Multiple sclerosis
  • Parkinson’s disease
  • Rheumatoid arthritis
  • Schizophrenia
  • Systemic lupus erythematosus
  • Ulcerative colitis

Controversy Around Prescribed Minimum Benefits

Medical aids pay for medical services, procedures and medication by pooling the monthly contributions of all its members and then paying out where and when necessary. Younger and healthier members are less likely to utilise a significant amount of medical services. In this way a medical aid can fund the services for those who require more medical care, like the elderly. Medical aids are not meant be a benefit that one has to use every year in full. Many members fail to understand that medical aid cover is a form of insurance and protection only for when they fall ill or are injured.

The legislation surrounding the prescribed minimum benefits, while intended to protect all medical aid members, did put schemes under pressure particularly with members on lower plans that are traditionally cheaper. In 2010 and 2011 there has been much media attention surrounding the prescribed minimum benefits and a misconception by many that medical aids are trying to bypass the legislation. However, the argument by medical schemes is that the legislation allows for medical providers, particularly hospitals and specialists, to charge any rate for those services laid out as a prescribed minimum benefit.

As any person utilising private healthcare services in South Africa will know, some medical providers charge above the medical aid rate (previously BHF rate, now the NHRPL rate). Where the medical aid will not pay for the amount above the NHRPL rate, medical aid members had to make up for the difference out of their own pocket. The amendment to the Medical Schemes Act with regards to prescribed minimum benefits (PMBs) did not clearly stipulate that medical providers are limited in the rates they charge for these conditions. This ultimately placed medical aids in a precarious situation as they have to pay for the rates demanded by medical providers.

If the legislation is not amended further, or medical providers are not willing to adhere to predetermined rates, it is possible that many medical aids will suffer a severe financial loss.

Vitacare Health is an independent online publication and is not affiliated with any medical aid, government department, related medical council or professional medical association.