Guide to Prescribed Minimum Benefits (PMBs)

 

Below is information about the guide to prescribed minimum benefits (PMBs) for 2024.

What are Prescribed Minimum Benefits?

Prescribed Minimum Benefits (PMBs) refer to a specific set of healthcare benefits that all medical schemes in South Africa are mandated to provide to their beneficiaries, as stipulated by the Medical Schemes Act 131 of 1998 and its accompanying regulations. This legislation ensures that individuals enrolled in medical schemes have access to essential healthcare services, safeguarding their health and well-being.

PMBs are categorized into three main groups:

1. Life-threatening emergency medical conditions: This category includes situations where immediate medical intervention is necessary to prevent death or serious harm.

2. 271 medical conditions defined in the Diagnostic Treatment Pairs: This extensive list encompasses various medical conditions for which treatment protocols have been established.

3. 26 chronic conditions, known as the Chronic Disease List conditions: These are long-term health issues that require ongoing management and treatment.

When are benefits considered for payment as Prescribed Minimum Benefits?

Benefits related to the 26 chronic conditions, the 271 medical conditions defined in the Diagnostic Treatment Pairs, and emergencies are considered for payment as PMBs. To qualify for coverage, both the condition and the treatment must be included in the established list of PMB conditions.

To determine whether a specific treatment qualifies for PMB funding, it is essential that we receive all necessary information from you and your healthcare providers. This includes medical records, treatment plans, and any other relevant documentation that can support your case.

It is important to note that there are specific requirements that must be met in order to qualify for PMBs. Medical schemes utilize various criteria for assessment, including the ICD-10 code, which is a diagnostic code used to verify if a condition qualifies for PMB coverage. However, it is crucial to understand that having the correct ICD-10 code does not automatically guarantee funding for the benefit as a PMB.

What happens once your condition and treatment is confirmed as a Prescribed Minimum Benefit?

Once your condition and treatment have been confirmed as qualifying for PMB coverage, the claims associated with these treatments will be processed for payment. However, there may be instances where your claims are not fully covered, even if the ICD-10 code suggests that the condition falls under PMBs. This could occur if certain criteria are not satisfied, such as seeking treatment from a non-designated provider or using non-formulary medications, or if the treatment does not align with the prescribed level of care for PMBs. If you ever have questions regarding the requirements for PMBs, we encourage you to reach out to us through our various communication channels for clarification.

When are Prescribed Minimum Benefits covered in full?

For Momentum Medical Scheme to cover PMBs in full, specific requirements must be adhered to. These requirements include, but are not limited to:

• You must obtain pre-authorisation for both in-hospital and out-of-hospital PMB treatments prior to or during the treatment process.

• You must not be subject to a waiting period or a condition-specific exclusion under your membership.

• You need to register for the health management program or chronic management program for your specific condition and comply with the program's criteria.

• You are required to utilize Momentum Medical Scheme's Designated Service Providers or adhere to the medicine formularies provided (please note that option-specific co-payments may apply).

• The treatment must fall within the appropriate level of care for PMBs as defined for that specific condition and must adhere to evidence-based protocols and guidelines, ensuring clinical appropriateness and cost-effectiveness.

• You must comply with the managed care principles or eligibility criteria established by Momentum Medical Scheme, which we will explain to you when you contact us for pre-authorisation.

• Your claims must include the authorized ICD-10 and treatment codes.

If you fail to meet any of these requirements, there is a possibility that PMBs may not be fully covered by Momentum Medical Scheme, and you may incur co-payments or face shortfalls in coverage.

Requirements for the 26 chronic conditions, known as the Chronic Disease List conditions

For the treatment of the 26 chronic conditions, it is necessary for either your treating doctor or pharmacy to contact us to register you on the chronic management program. We will require comprehensive details regarding your diagnosis, the prescribed treatment, and specific test or scan results pertinent to your condition. If your registration is approved, benefits will be disbursed in accordance with an established treatment plan and the relevant medicine formularies.

Requirements for the 271 medical conditions defined in the Diagnostic Treatment Pairs

For the 271 medical conditions listed in the Diagnostic Treatment Pairs, it is essential that you obtain pre-authorisation for the required treatment. This process may include registering on a health management program. We will need detailed information about your diagnosis and treatment, along with any supporting test or scan results for specific conditions. If your request is approved, the benefits will be paid according to the treatment that has been authorized.

Out-of-hospital treatment for a confirmed Prescribed Minimum Benefit condition

For out-of-hospital treatments related to a confirmed PMB condition, your treating doctor must complete the Momentum Medical Scheme Prescribed Minimum Benefit application form and submit it to us for pre-authorisation. You or your healthcare providers may need to provide results from medical tests, x-rays, scans, pathology tests, and any other relevant documentation or justification to facilitate the authorization of the treatment for PMB payment. Approval will be based on clinical policies and evidence-based therapeutic practices.

Life-threatening emergencies

In the case of a life-threatening emergency, you are permitted to seek treatment from the nearest medical facility, as there may not be sufficient time to reach a Designated Service Provider. However, it is important to remember that other criteria still apply, such as ensuring that the level of care provided is appropriate for the situation.

What are your responsibilities regarding Prescribed Minimum Benefits?

While medical schemes are legally required to provide coverage for PMBs, it is equally important for you to understand and fulfill certain responsibilities:

• Understand your condition: It is vital for you to familiarize yourself with the PMB conditions and treatments that are covered under your Momentum Medical Scheme benefit option. This information can be found on our website and in your member brochure. It is crucial to recognize that you must meet the eligibility criteria, and we need to receive the necessary information to assess whether your condition or treatment qualifies for PMB coverage.
• Use Designated Service Providers (DSPs): To avoid potential shortfalls or co-payments, you must utilize the Designated Service Providers associated with Momentum Medical Scheme for PMB conditions. This requirement is waived only in emergency situations where you have no choice of healthcare provider. These DSPs are established to ensure you receive healthcare treatment at the most favorable industry rates. If you choose to seek treatment from a provider outside the DSP arrangement for PMB services, the Scheme may not fully cover the costs, even if your plan allows for provider choice. You may be responsible for paying the difference or a higher co-payment for using non-designated providers.
• Use medicine formularies: To prevent shortfalls or co-payments, you must adhere to the medicine formularies established by Momentum Medical Scheme for PMB conditions. You can find the details regarding formulary medicines on your benefit option, along with information about applicable co-payments for your chronic medications by logging into momentummedicalscheme.co.za.
• Ensure relevant and accurate information is shared with us: It is essential that all pertinent and accurate information is communicated to us to facilitate the smooth processing of your claims and eligibility for PMBs.