Understanding PMBs: your guide to maximising medical scheme benefits and avoiding unexpected costs

By law, medical schemes are bound to pay for costs related to 271 defined diagnoses and 27 chronic diseases that qualify for prescribed minimum benefits (PMBs).

The diagnoses covered under the Medical Schemes Act include tuberculosis, HIV infection and cancer, and the chronic conditions include asthma, epilepsy and high blood pressure.

Medical expenses for these conditions are paid out from the scheme’s combined risk pool and not from your day-to-day benefits or your medical savings account.

The key provisions that regulate the funding of PMBs by your medical scheme under the Medical Schemes Act include:

Benefit conditions must be paid in full, according to the invoice submitted by your healthcare provider such as your doctor, specialist or hospital.

Your scheme is not allowed to use your personal medical savings account to pay for benefit conditions.

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Your scheme is entitled to nominate a designated service provider such as a doctor, pharmacy or hospital as the first-choice provider when you need treatment or care for a PMB condition. Read the fine print in your medical scheme documents. If a designated service provider is required under the option you choose, and you use a doctor or hospital that is not such a provider, you may end up having to pay a hefty copayment. In the case of an emergency in which you have no choice but to use the nearest provider, the scheme may make an exception, but it will request proof that the event was indeed a medical emergency.

You usually have to register a chronic condition on the PMB list with your medical scheme before your costs are paid as such. Jeremy Yatt, principal officer of Fedhealth, says you would typically have to submit information such as the name of your doctor, the doctor’s practice number, the diagnosis or ICD-10 code, the name of the medication you require, the strength of the medication and the directions for use (how much you need how often).

You might not need to provide additional motivations or supporting documents for conditions such as high blood pressure and asthma. However, you should check because this may vary between schemes. For example, if you have high cholesterol, you might have to submit a copy of lipogram values or a pathology report.

If you need chronic medication such as an asthma pump, there are usually no limits, but your scheme may require that you use a generic equivalent of the medication, or that you must buy the inhaler from a particular pharmacy network with which the scheme has negotiated preferential rates.

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If you then choose to use a more expensive inhaler or a different pharmacy, you will probably have to pay a copayment out of your own pocket. 

Generic medication has the same active ingredient as the original product and is usually much cheaper, saving you money.

One of the grey areas that has remained since PMBs were introduced more than 20 years ago surrounds medical emergencies. Problems typically arise when something that appears to be a medical emergency is diagnosed and found to be a non-emergency.

In such a case, your scheme can decline payment for consultations in hospital emergency rooms, leaving you to foot the bill. DM

This story first appeared in our weekly Daily Maverick 168 newspaper, which is available countrywide for R35.