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Doesn’t it feel like your medical aid is paying less and less but your contribution towards the scheme is soaring? If you belong to a private medical aid scheme in RSA, I can guarantee you that each year you are getting less bang for your buck! It’s a tough pill to swallow isn’t it? What’s hurts even more is that your choice of medical aid plan is based solely on your affordability. Fatter wallets get access to wider private health care choices and better coverage. Skinny wallets, trying to negotiate a tricky budgeting tight rope each month, have fewer plan options. But surely medical aid schemes should be picking up the costs of certain conditions regardless of what plan you are on?

Yes, they should and, by law, they must. Medical Aid Schemes in this country are legally obliged to pay for in full the treatment of certain conditions regardless of plan type. I’m referring to a list of “Prescribed Minimum Benefits” or PMB’s and this is what you need to know about them.

PMb’s were introduced in line with the Governments Health Policy and since 2004 medical schemes have been required to fund the costs of PMB medicine, cover the cost of reasonable tests to confirm the PMB condition or disease and all costs associated with descriptions of PMB treatment as set out in law.

So what’s actually covered in this PMB list?

The Prescribed Minimum Benefit list covers:

1) Emergency Conditions

2) Chronic Disease List

There are just too many conditions to list in this post, so I would suggest that you download a copy of the PMB list after reading this post. A link to the PMB list will be provided at the end of this article.

How can I be sure that my Medical Aid Scheme is going to pay for these PMB’s in full?

Now that’s a good question. You don’t need to worry about your scheme paying for these costs in full because by law they are obliged to.

The Regulations of the Medical Schemes Act of 1998 clearly states:

“Prescribed Minimum Benefits.—(1) Subject to the provisions of this regulation, any benefit option that is offered by a medical scheme must pay in full, without co-payment or the use of deductibles, the diagnosis, treatment and care costs of the prescribed minimum benefit conditions.”

What you do need to make sure of is that the treatment of your PMB falls within the parameters afforded to your medical aid scheme by government.

You see, before PMB’s were made compulsory medical aid schemes could control their liabilities by simply listing commonly required treatments for emergencies and chronic diseases in more expensive plan options. So as a scheme member you might not have had these conditions covered in full unless you paid extra to be on a more comprehensive plan. The real problem is that no medical scheme could afford to fund PMB’s with no limits in place. The law had to provide options to medical aid schemes to ensure the costs to the schemes are manageable:

Today Medical Aid Schemes can:

1) Appoint Designated Service Providers  (DSP’s)

2) Have formularies (medicine lists) & treatment plans in place for PMB’s

So what does that mean to you?

The cost of the PMB will be covered by your medical aid scheme provided that you use a designated service provider. If you don’t use a provider chosen by your scheme, the scheme can impose a co-payment. That of course means that the PMB isn’t going to be covered in full because you will be liable for a partial payment.

The Medical Schemes Act of 1998 says the following:

“The diagnosis, treatment and care costs of a prescribed minimum benefit condition will only be paid in full by the medical scheme if those services are obtained from a designated service provider in respect of that condition.”

The scheme is also allowed to have their own treatment protocols in place for PMB’s and their own medicine lists. That simple means the scheme can choose how they are going to treat the PMB condition and which treatment plan to follow. There aren’t however allowed to use funds in your medical savings accounts to pay for the costs of PMB treatment!

Your medical aid is a vital bit of insurance. Make sure that you know which PMB conditions your medical aid scheme is obliged to pick up in full.

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