Our Health Minister Aaron Motsoaledi recently raised a few eyebrows with some controversial comments. It looks like some sweeping changes are on the way, and one of the targets is medical scheme PMBs and co-payments? While some of you might nod your head in agreement, most people, who belong to a medical scheme, don’t even know what a PMB is. In this blog post we’ll introduce you to the term PMB, and touch on an ongoing problem in the private healthcare space that’s lead to the scrutiny.
What is a PMB?
As a medical aid member, do you enjoy the same benefits as your fellow scheme member? The answer is No! Our guess is that you knew that already. Those members with more bucks pay higher contributions, and enjoy more comprehensive benefits. Those scheme members with fewer bucks – well let’s just say their coverage isn’t as comprehensive.
You get what you pay for, right?
“But there is something horribly unfair about that”, I hear you mutter. “Shouldn’t all medical scheme members enjoy a certain level of coverage? I mean regardless of your medical aid plan type, shouldn’t medical schemes be picking up certain costs in full?”
PMB stands for “Prescribed Minimum Benefits“
Simply put, it’s a list of conditions that your medical scheme needs to pay in full, regardless of the plan type you are on. Now without boring you to death with a ton of detail, this is what you really need to know about PMBs.
It’s law. Your medical scheme needs to pay for PMB conditions in full. “Why is that?” The Regulations of the Medical Schemes Act of 1998 clearly state: “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’s covered in the PMB list?
- Any emergency medical condition
- 270 medical conditions
- 25 chronic conditions
Your medical scheme might be forced to pay the PMBs in full, but they can ask you to tow the line. You see, because no medical aid scheme can afford to simply open themselves up to limitless payouts, they needed to be offered a little room to move. The law had to provide options to medical schemes to ensure the costs remained manageable. So your medical scheme are within their rights to:
- Appoint Designated Service Providers
- Have Formularies (medicine lists) & treatment plans in place
What does that mean?
Your scheme has to pick up the cost of you PMBs in full but they will ask you to use a designated service provider (DSP). If you chose not to use a DSP, your scheme can (and will) hit you with a co-payment. Your medical scheme is also allowed to have their own treatment protocols in place to handle PMBs. All that means is that your scheme can choose how to treat your PMB condition.
So what is all the ruckus about?
The problem is that there aren’t any regulations in place on how much a healthcare provided can charge a medical scheme. Think about that for a second. PMBs have to be covered by your scheme, but tariffs aren’t regulated and healthcare providers can charge what they like. That’s a serious problem if you are a medical scheme, right?
It’s a bit of a free-for-all at the moment. We used to have a National Health Reference Price List (NHRPL) in place that was supposed to provided a tariff guideline, but a High Court ruling in 2008 scrapped the NHRPL. Now medical aid schemes are left to negotiate their own deals with healthcare providers, and those that are bigger can negotiate bigger discounts. The smaller schemes can’t, and healthcare providers end up charging them more. It’s putting a massive strain on schemes and their ability to provide PMB benefits.
That’s the unfortunate reality of the current situation. It’s not sustainable.
The good news is that there is a discussion underway to provide a new set of PMBs, with more focus on preventative care and to regulate the charges healthcare providers can levy against medical schemes for products and services.
We will watch the space and keep you posted on any new developments.
Until next time.
The Wise About Life team