According to Dr Rajesh Patel, head of benefit and risk at the Board of Healthcare Funders (BHF), diagnosis based prescribed minimum benefits (PMBs) are discriminatory, as “if you suffer from a disease that is not on that list it means you are not entitled to any prescribed benefits.”
The Council for Medical Schemes (CMS) explained: “PMBs refer to the scope and the level of minimum benefits that are to be available to beneficiaries as may be prescribed by the Minister of Health. The aim of PMBs was to provide protection from catastrophic out of pocket expenditure, prevent dumping into public healthcare sector and improve risk cross subsidisation.”
But Patel believes there needs to be a review of PMB benefits and that the list and treatments should be easily accessible: “I would prefer to see PMBs rewritten in a format where it prescribes essential benefits, so it lists essential medicines, and whatever diseases those drugs treat, it’s available. The way it is listed right now, unfortunately, some people get and others do not.”
According to Patel, the problem is that there are too few conditions that have PMB status. And while there are many treatment options for these PMBs, Patel feels that it would be better if there were more conditions listed as PMBs and fewer treatment options. “What I would prefer to see is breadth of benefits that the majority of members can [benefit from], it may not necessarily be as deep as it is right now, but I would prefer it sort of a breadth type of thing because that’s consistent with our constitution.”
Inaccessibility of PMB list
Moneyweb recently released a report highlighting the difficultly that some of its users had at accessing the list of 270 conditions that are covered by PMBs. These conditions are in addition to the 26 chronic conditions that are covered and medical emergencies.
While the list for the 270 conditions with PMBs was difficult to attain, the list of the 26 chronic conditions and their treatments is readily available.
Following an investigation Moneyweb found that these conditions were not easily accessible, and that some medical schemes would not send them to their members when asked. However, following the investigation, these are now readily available on the CMS website, as well as some of the medical schemes’ websites.
However, Patel noted that despite the claims that the list of 270 conditions was hard to find, it has been in the public domain since 1999 when they were published in the Government Gazette.
The CMS revealed to Justmoney: “The list is available on the Council for Medical Schemes' website. However, medical schemes should actually also make the list available to their members. The document provided on CMS website provides information about 270 listed conditions classified according to organ-system chapters, starting from the brain and nervous system and ending up with mental illness.
Identifying a PMB
For any condition that appears on the PMB list, medical schemes are required to provide the treatment that is allocated.
The CMS noted: “Some medical schemes state in their rules that members have to register for PMBs in order to get full benefit. However, there are schemes that do not inform members about this process, which is contravening the Medical Schemes Act, 131 of 1998.”
Patel revealed that since 2005, it has been mandatory for all service providers to submit ICD10 codes.
The ICD10 code will alert the medical scheme if the condition that you are being treated for is a PMB, noted Patel. However, he stressed that just because there is an ICD10 code, it does not mean that the condition is a PMB.
The CMS explained: “In isolation, ICD10 codes alone are seldom enough to correctly identify PMB benefits since the PMB regulations define PMB benefits as a diagnosis with specified severity, in relation to specified treatment. The onus is on the treating physician to provide a discharge summary that could be used as additional information to assist in identifying PMB claims.”
Furthermore, the CMS highlighted that PMBs should be reviewed every two years, and it is currently in the process of doing so.
“It is important to note that PMB are the pillars of the Medical Schemes Act 131 of 1998.
The diagnosis, treatment and care costs of PMBs should be paid according to the PMB regulation. The interpretation of the PMB’s should follow the predominant public hospital practice,” added the CMS.