Prescribed Minimum Benefits (PMBs)
This information has been prepared to assist you in understanding the legislation, administrative processes and your rights regarding Prescribed Minimum Benefits (PMBs). It is important that you read this information carefully and completely.
What you must do if you have a PMB Condition
- Please read the law regarding PMB’s provided below and familiarize yourself with your statutory rights and responsibilities.
- If you believe you have a valid complaint against your scheme, or would like apitional information regarding PMBs, please contact the Council for Medical Schemes (CMS) for further assistance. Their details are as follows: Tel: 012 431-0500 / 0861 123 267 , Fax: 012430-764 , E-mail: email@example.com, www.medicalschemes.com
- It is your responsibility to inform your medical scheme of the diagnosis and to inquire whether any apitional program registrations are required, such as chronic conditions or oncology benefits. It is also your responsibility to register for these programs as soon as possible after the diagnosis has been definitely secured. You may need to deliver the appropriate pathology reports and other supportive documentation.
- I am a designated service provider (DSP) for the following scheme types only: Discovery Classic Saver, Discovery Classic Comprehensive and Discovery Executive. If you are on these plans, your account should be paid in full. If you are not, you should discuss your surgery with your Scheme and ascertain if they have a DSP agreement with another surgeon and if that surgeon is able to provide you with the surgical procedure that you require.
- If you are not a member of the above schemes for which I am a DSP, and you choose to have your surgery with me, then according to the law, you may be liable for a co-payment as per the rules of your scheme.
- If you have been referred to me as a hospital inpatient, in many cases this would constitute an “involuntarily obtained service” and according to the law would require the scheme to pay in full. Such cases are typically fraught with significant administrative burdens. It remains the responsibility of the patient or their relatives to persuade their scheme to abide by the law. My office will assist as much as possible, but the responsibility remains that of the patient and/or their guarantor.
- All patients should be aware that final payment of accounts will remain the sole responsibility of the patient and/or their guarantor, the applicability of a PMB diagnosis notwithstanding. We require payment in full within 14 days of the procedure, as per my terms and conditions of service.
The Prescribed Minimum Benefits (PMBs) appear in Annexure A to the Regulations under the Medical Schemes Act. They are prescribed in terms of section 29(1))(o) of the Act which states that schemes must provide in their rules for the scope and level of minimum benefits that are to be available to beneficiaries as may be prescribed. In the Regulations, regulation 8 contains provisions relating to PMBs as follows –
- 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.
- Subject to section 29(1)(p) of the Act, the rules of a medical scheme may, in respect of any benefit option, provide that-
- (a) the diagnosis, treatment and care costs of a prescribed minimum benefit condition will only be paid in full by the medical scheme if those services are obtained from a designated service provider in respect of that condition; and
- (b) a co-payment or deductible, the quantum of which is specified in the rules of the medical scheme, may be imposed on a member if that member or his or her dependent obtains such services from a provider other than a designated service provider, provided that no co-payment or deductible is payable by a member if the service was involuntarily obtained from a provider other than a designated service provider.
- For the purposes of subregulation (2)(b), a beneficiary will be deemed to have involuntarily obtained a service from a provider other than a designated service provider, if-
- (a) the service was not available from the designated service provider or would not be provided without unreasonable delay;
- (b) immediate medical or surgical treatment for a prescribed minimum benefit condition was required under circumstances or at locations which reasonably precluded the beneficiary from obtaining such treatment from a designated service provider; or
- (c) there was no designated service provider within reasonable proximity to the beneficiary’s ordinary place of business or personal residence.
- Subject to subregulations (5) and (6) and to section 29(1)(p) of the Act, these Regulations must not be construed to prevent medical schemes from employing appropriate interventions aimed at improving the efficiency and effectiveness of health care provision, including such techniques as requirements for pre-authorisation, the application of treatment protocols, and the use of formularies.
- When a formulary includes a drug that is clinically appropriate and effective for the treatment of a prescribed minimum benefit condition suffered by a beneficiary, and that beneficiary knowingly declines the formulary drug and opts to use another drug instead, the scheme may impose a co-payment on the relevant member.
- A medical scheme may not prohibit, or enter into an arrangement or contract that prohibits, the initiation of an appropriate intervention by a health care provider prior to receiving authorisation from the medical scheme or any other party, in respect of an emergency medical condition.