What are PMBs?
Prescribed Minimum Benefits (PMB) is a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. The aim is to provide people with continuous care to improve their health and well-being and to make healthcare more affordable.
PMBs are a feature of the Medical Schemes Act, in terms of which medical schemes have to cover the costs related to the diagnosis, treatment and care of:
- any emergency medical condition;
- a limited set of 270 medical conditions (defined in the Diagnosis Treatment Pairs);
- and- 25 chronic conditions (defined in the Chronic Disease List).
When deciding whether a condition is a PMB, the doctor should only look at the symptoms and not at any other factors, such as how the injury or condition was contracted. This approach is called diagnosis-based. Once the diagnosis has been made, the appropriate treatment and care is decided upon as well as where the patient should receive the treatment (at a hospital, as an outpatient or at a doctor’s rooms).
Why do we have PMBs?
There are two main reasons why PMBs were created:
- To ensure that medical scheme beneficiaries have continuous healthcare. This means that even if a member’s benefits for a year have run out, the medical scheme has to pay for the treatment of PMB conditions.
- To ensure that healthcare is paid for by the correct parties. Medical scheme members with PMB conditions are entitled to the specified treatments and these have to be covered by their medical scheme, even if the patients were treated at a state hospital.
But there are other valid reasons too:
- To provide minimum healthcare to everybody who needs it, regardless of their age, state of health or the medical scheme cover option they belong to.
- PMBs have a part to play in ensuring that medical schemes remain financially healthy. When beneficiaries receive good care on an ongoing basis, their general wellness improves, resulting in fewer serious conditions that are expensive to treat.
- To protect the interests of medical scheme beneficiaries by ensuring, for instance, that schemes first cover essential treatments before setting funds aside for discretionary services.
READ MORE ON PMB’s at http://www.medicalschemes.com/medical_schemes_pmb/index.htm
affordable medical aid / affordablemedicalaid.