In our last blog post, we started looking at some of the nitty gritty of medical aids, namely late joiner penalties, waiting periods and condition specific periods. In this blog, we will look at prescribed minimum benefits and chronic conditions.
What are PMBs or Prescribed Minimum Benefits?
Prescribed Minimum Benefits (PMBs) 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, where medical schemes have to cover the costs related to the diagnosis, treatment and care of:
- Any emergency medical condition.
- 271 PMB medical conditions.
Why do I have PMB cover?
There are two main reasons why PMBs were created:
- Providing medical scheme members with a level of healthcare regardless what plan they are on. In other words, PMB conditions are covered even in the event that a member’s benefits for the year have expired; and
- To ensure that healthcare is paid for by the correct parties. All medical scheme members with PMB conditions are entitled to the specified treatments and those treatments must be covered by their medical plan, even if the patients were treated at a state hospital.
How do I apply for PMB cover on my medical aid?
Your treating doctor needs to complete a PMB application provided by your medical aid. This will then be submitted to your medical aid for review and you will then be issued with a basket of care. The basket of care will advise what benefit you have access to on your PMB benefit.
Example:
Peter has been diagnosed with Major Depression. Peter’s doctor has applied for the PMB benefit and he has been approved for 15 outpatient psychiatry visits in his basket of care along with his prescribed medication being covered in full.
How long does my PMB last?
Your benefit or treatment plan will last for a period of 12 months. Your doctor will need to renew your PMB benefit with the medical aid every twelve months.
What is the chronic Illness benefit (CIB)?
When joining a Medical Aid, you have access to cover for the 26 Prescribed Minimum Benefit (PMB) Chronic Disease List (CDL) conditions.
This is a defined list of conditions all medical scheme members have cover for to ensure access to certain minimum healthcare services, regardless of the Option they chose.
This cover includes funding for the diagnosis, recommended treatment and ongoing care for the listed conditions.
How do I access my Chronic Illness benefit?
Like with PMBs, if you want to access cover from the Chronic Illness Benefit, you must apply for it. A Chronic Illness Benefit application form must be completed with your doctor and submitted for approval.
You need to meet the benefit entry criteria for your condition to be registered on the Chronic Illness Benefit. You or your doctor may need to provide certain test results or extra information as indicated on the Chronic application form for the condition you are applying for.
Please ensure that these documents are submitted with your application to avoid any delays in the process.
Once you are approved for the Chronic Benefit, the medical aid will provide you with a basket of care. In the basket of care, you can find out what benefits you have been approved for and how your medical aid will be covering your treatment.
Where can I get my chronic medication?
You can obtain your chronic medication from a pharmacy on your medical aid network or from your treating doctor.
Some medical aids will offer their clients the option to have their medication delivered to them by using their designated provider.
Does my Chronic Benefit expire?
The medical aid will not require you to renew your coverage once it has approved your chronic condition. You should notify your medical aid if your medication has changed or if you are being treated for a new chronic condition that the medical aid is not aware of.
For those with PMBs or Chronic conditions, please make sure that your doctor registers you for the PMB or Chronic Benefit so that you can make use of all medical aid benefits without having to pay out of pocket for your treatment.
We hope this has helped you to understand some of the nitty gritty or technical terms used with medical aid. In our next blog, we will be looking at immigrating or travelling with medical aid.
Prescribed Minimum Benefits (PMBs) 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.
Chronic Illness benefit (CIB) – When joining a Medical Aid, you have access to cover for the 26 Prescribed Minimum Benefit (PMB) Chronic Disease List (CDL) conditions. This is a defined list of conditions all medical scheme members have cover for to ensure access to certain minimum healthcare services, regardless of the Option they chose. This cover includes funding for the diagnosis, recommended treatment and ongoing care for the listed conditions.
You should notify your medical aid if your medication has changed or if you are being treated for a new chronic condition that the medical aid is not aware of.
For those with PMBs or Chronic conditions, please make sure that your doctor registers you for the PMB or Chronic Benefit so that you can make use of all medical aid benefits without having to pay out of pocket for your treatment.
