The Benefits That Medical Schemes Must Provide

There is a relatively wide range of medical conditions and procedures that medical schemes are required by law to cover in full, no matter which plan you are on … and they cannot raid your medical savings account to do so. These are known as Prescribed Minimum Benefits (PMBs).

Medical schemes in South Africa fall under the Medical Schemes Act of 2018, which has stringent consumer-protection requirements – this differentiates schemes from insurance companies that offer medical insurance policies. The Act makes provision for a set of benefits related to medical emergencies and life-threatening conditions that schemes must cover, including funding the diagnosis, treatment and ongoing care of these conditions.

According to the Council for Medical Schemes (CMS), which regulates schemes in accordance with the Act, “PMBs are designed to protect members from high healthcare costs for serious illnesses or emergencies”.

Importantly, PMBs must be covered in full by the scheme (with certain conditions attached), they must apply to all plans, or options, offered by the scheme, and they must be funded from the risk portion of your contributions, not the portion that may go into a medical savings account for day-to-day medical expenses.

While ensuring members are properly covered for life-threatening conditions, PMBs add considerably to the cost of cover, explaining why medical scheme membership is so expensive and why it rises by more than the CPI inflation rate each year.

If you belong to a medical scheme, you need to ensure that the scheme correctly covers any PMB conditions you or your family may have. After all, you are paying for this protection.

What conditions are covered?

There are three categories of conditions covered by PMBs:

1. Chronic conditions. While excluding many chronic conditions, PMBs cover treatment for 27 serious ones. Common conditions included are diabetes (Type 1 and Type 2), hypertension (high blood pressure), hyperlipidaemia (high cholesterol and/or triglycerides) and asthma. Click here to view the list.

2. Medical emergencies. These are injuries and acute conditions which, if not treated immediately, could pose a serious risk to your health or life. Examples are heart attack, stroke, and severe allergic reactions (anaphylaxis).

3. Specified conditions. There are 271 life-threatening medical conditions requiring specific treatments, referred to as Diagnosis and Treatment Pairs (DTPs). They range from common illnesses such as pneumonia to appendicitis, tuberculosis and cancer. Access the full list of DTPs here. These DTPs have treatment codes (ICD-10 codes) identifying them to the medical scheme as PMBs.

Medical scheme requirements

Schemes are entitled to contain their costs of covering PMB conditions by placing certain requirements on members. They do this by:

• Having established treatment protocols for certain conditions.

• Requiring members to use medication from a prescribed medicine list.

• Having designated service providers and hospital networks in place for treating and managing PMBs.

If members do not adhere to the treatment and medication protocols established by the scheme, they are unlikely to be covered in full. Restrictions or penalties include: 

• Co-payments (payments from your own pocket) for using a service provider or medication that is not on the scheme’s list or in its provider network.

• Waiting periods that include PMBs. If you have had a break in cover of more than 90 days or have not belonged to a medical scheme in the past, the scheme may impose a waiting period which may apply to PMB conditions.

• Co-payments for using alternative, unauthorised treatments or failing to pre-authorise your treatment or hospitalisation.

These requirements must be explained in the terms and conditions of your membership.

Your rights as a member

You have the right to receive necessary care without discrimination on factors such as age or health and the right to lodge a complaint if PMB treatment is denied or if it is not covered in the correct way. If you believe your medical scheme is not fulfilling its PMB obligations, you should:

• Follow the steps outlined by your scheme for filing complaints.

• Contact the CMS if you have exhausted your scheme’s complaints process. Learn more about the CMS complaints procedure here.

References:

“What are Prescribed Minimum Benefits?” (CMS)

“A guide to understanding Prescribed Minimum Benefits” (CMS)

“Prescribed Minimum Benefits and Chronic Medication” (CMS booklet – 2011)

“What is a prescribed minimum benefit?” (Smart About Money)

“What you need to know about prescribed minimum benefits” by Rachel Janssens (IOL)