Prescribed Minimum Benefits and Medical Aids

    What are Prescribed Minimum Benefits?

    • These are basic benefits that medical aids must cover by law
    • A list of 25 chronic conditions fall under the ambit of this cover
    • The benefits also cover about 270 different at present
    • Every medical scheme must offer these benefits to each member
    • The PMB apply no matter what level of cover you choose.

     

    All medical aids and plans must, by law, offer some basic benefits to members. According to the Medical Schemes Act, any medical aid or scheme is obligated to pay when it comes to the diagnosis, care, and treatment of:

    • A medical emergency when your life is at stake
    • A range of 25 conditions classified as chronic
    • A set of defined diagnoses – there are 270 in total. You can visit the website of the Council of Medical Schemes for more details of these.

    The  Prescribed Minimum Benefits (PMB) cover that.

    When do Prescribed Minimum Benefits Come into Effect?

    As long as the client is using a designated service provider, they may avail of the benefits without having to worry about a co-payment or a deductible. The medical aid is allowed to apply its own protocol and formulary when it comes to the Prescribed Minimum Benefitsuse of chronic medication.

    Members can apply for these benefits when they run out of their existing benefits.

    Members have to follow the normal procedure of getting pre-authorisation when going into hospital. Without this, the medical scheme may not be liable for paying these benefits.

    The Cost of Not Using a Designated Service Provider

    If the member of the scheme opts to use a service provider other than those designated, the medical aid may impose co-payments or stiff penalties.

    They are also able to refuse payment if the member went to someone outside the network provided that:

    • You could have got the same service from a designated service provider in a reasonable amount of time.
    • There was a DSP within a reasonable proximity of where the member lives or works
    • The situation was not an emergency

     

    The medical aid asks for a written explanation of why you did not go to the designated service provider.

    Can the Schemes Apply Limits for Chronic Medications?

    The scheme may apply limits when it comes to amount of chronic medication you receive. You pay for all chronic medication out of your overall chronic medication limit. This is irrespective of whether or not it is covered under the prescribed minimum benefits.

    That said, if you do reach those limits, the scheme MUST pay for chronic medication related to conditions covered by the prescribed minimum benefits.

    Will I Need to Get Authorisation for Chronic Medication?

    Even when the chronic medication falls under the list of prescribed conditions, you will still need to apply to have it covered by your medical aid. This will usually involve the completion of a form by yourself and your doctor.

    The medical aid dictates which medications you can use based on its formulary and also where you can get them from.

    Solution: complete and submit the form on this page to sign up for gap cover at Zestlife