Guide to Prescribed Minimum Benefits (PMBs)

 

Below is a guide to Prescribed Minimum Benefits (PMBs)

This document aims to provide a comprehensive overview of Prescribed Minimum Benefits (PMBs) and explain how the Momentum Medical Scheme supports our beneficiaries in accessing these essential benefits.

What are Prescribed Minimum Benefits? Prescribed Minimum Benefits are a specific set of healthcare services that all medical schemes in South Africa are mandated to provide coverage for, as stipulated by the Medical Schemes Act 131 of 1998 and its associated regulations. These benefits are designed to ensure that all medical scheme members receive essential healthcare services, especially in critical situations. PMBs are categorized into three main groups: first, there are life-threatening emergency medical conditions that require immediate attention; second, there are 271 medical conditions that are specifically defined within the Diagnostic Treatment Pairs; and third, there are 26 chronic conditions that are recognized as part of the Chronic Disease List. For more detailed information about Prescribed Minimum Benefits and the specific conditions that are covered, please click here.

When are benefits considered for payment as Prescribed Minimum Benefits? To determine when benefits can be classified as Prescribed Minimum Benefits, several factors must be taken into account. This includes the 26 chronic conditions listed in the Chronic Disease List, the 271 medical conditions outlined in the Diagnostic Treatment Pairs, and any emergencies that arise. It is crucial that both the condition and the treatment provided are included in the officially defined list of Prescribed Minimum Benefit conditions.

To assess whether a particular condition and its corresponding treatment qualify for coverage as a Prescribed Minimum Benefit, we must receive comprehensive information from you as well as from your treating healthcare providers. This information is essential for our consideration. Additionally, there are specific requirements that must be met to qualify for these benefits. Medical schemes evaluate various criteria, including the ICD-10 code, which serves as the diagnostic code used to verify if a condition meets the criteria for a Prescribed Minimum Benefit. However, it is important to note that the presence of an ICD-10 code alone does not guarantee that the benefit will be funded as a Prescribed Minimum Benefit. Therefore, thorough documentation and compliance with the requirements are necessary for successful claims.

What occurs once your condition and treatment are recognized as a Prescribed Minimum Benefit? Once your condition and the corresponding treatment have been officially recognized as a Prescribed Minimum Benefit, you can expect that your claims will be processed and paid according to the established guidelines. However, it is important to note that there may be instances where your claims are not fully covered, despite the ICD-10 code suggesting that your condition qualifies for Prescribed Minimum Benefits. This can happen if certain criteria are not met. For example, if you choose to receive treatment or medication from a non-designated provider, or if you opt for a medication that is not included in the formulary, your claims may be partially covered. Furthermore, if the treatment you receive does not align with the level of care defined under the Prescribed Minimum Benefits, this could also result in a lack of full coverage. Should you have any uncertainties regarding what is required to qualify for Prescribed Minimum Benefits, we encourage you to reach out to us through our various communication channels for clarification and assistance. When are Prescribed Minimum Benefits fully covered? For the Momentum Medical Scheme to provide full coverage for Prescribed Minimum Benefits, there are specific requirements that must be met. These requirements are designed to ensure that members receive appropriate care while adhering to the scheme's policies. Firstly, it is essential that you obtain pre-authorisation for both in-hospital and out-of-hospital treatments related to Prescribed Minimum Benefits, either prior to or during the course of treatment. Additionally, you must not be subject to any waiting periods or specific condition exclusions that would affect your membership status. Another crucial aspect is that you must register for the health management program or chronic management program that pertains to your condition, and you must follow the criteria set forth by these programs. It is also mandatory to utilize Momentum Medical Scheme’s Designated Service Providers or approved medicine formularies; please be aware that specific co-payments related to your chosen option may apply. Moreover, the treatment you receive must be consistent with the level of care designated for the specific condition under the Prescribed Minimum Benefits. This treatment must also adhere to the principles of funding allocation based on established evidence-based protocols and guidelines, ensuring that it is clinically appropriate and offers a favorable cost-benefit ratio. Additionally, you are required to comply with the managed care principles or eligibility criteria that are stipulated by Momentum Medical Scheme. We are more than willing to explain these requirements to you in detail when you reach out for pre-authorisation. Lastly, it is crucial that your claims include the authorized ICD-10 and treatment codes. Failure to comply with any of these stipulations may result in the Prescribed Minimum Benefits not being fully covered by Momentum Medical Scheme, and you may face co-payments or shortfalls. Requirements for the 26 chronic conditions, known as the Chronic Disease List conditions In order to access benefits for the 26 chronic conditions recognized under the Chronic Disease List, it is necessary for your treating doctor or pharmacy to contact us to initiate your registration on the chronic management program. We will need specific information, including details regarding your diagnosis, the prescribed medication, and certain test or scan results pertinent to your condition. If your registration is approved, the benefits will be disbursed in accordance with a predefined treatment plan and the corresponding medicine formularies. Requirements for the 271 medical conditions defined in the Diagnostic Treatment Pairs For the 271 medical conditions outlined in the Diagnostic Treatment Pairs, it is imperative that you obtain pre-authorisation for the required treatment. This process may also involve registering on a health management program. We will require comprehensive details about your diagnosis and the proposed treatment, as well as any relevant supporting test or scan results for certain conditions. If your request for treatment is approved, the benefits will be paid based on the treatment that has been authorized.

Out-of-hospital Treatment for a Confirmed Prescribed Minimum Benefit Condition In order to initiate out-of-hospital treatment for a condition that has been confirmed as a Prescribed Minimum Benefit (PMB), it is essential for the treating physician to complete the Momentum Medical Scheme Prescribed Minimum Benefit application form. This form must be submitted to our organization for the purpose of obtaining pre-authorization. It is important to note that either you or the treating doctors may be required to provide additional documentation, which may include the results of various medical tests such as x-rays, scans, and pathology tests. Furthermore, any other relevant documentation or motivation that supports the need for treatment may also need to be submitted to facilitate the authorization process, ensuring that the treatment qualifies for payment as a Prescribed Minimum Benefit. The approval of such requests is contingent upon adherence to clinical policies and the utilization of evidence-based therapies. Life-threatening Emergencies In the event of a life-threatening emergency, you are permitted to seek treatment from the nearest medical facility. This is particularly crucial when time is of the essence, as there may not be sufficient opportunity to travel to a Designated Service Provider (DSP). However, it is important to understand that even in these urgent situations, the other established criteria will still apply. For instance, the level of care provided must remain appropriate to the medical situation at hand.

Your Responsibilities Regarding Prescribed Minimum Benefits While medical schemes, including Momentum Medical Scheme, are mandated to provide coverage for Prescribed Minimum Benefits, it is equally important for you to understand and fulfill your responsibilities in this regard. First and foremost, it is vital to familiarize yourself with your specific medical condition. Understanding the Prescribed Minimum Benefit conditions and the treatments that are covered under your particular Momentum Medical Scheme benefit option is essential. This information can be readily accessed on our website or within your member brochure. It is crucial to note that you must meet the eligibility criteria, and we require the necessary information to determine whether your condition or treatment qualifies as a Prescribed Minimum Benefit. Another important responsibility is the use of Designated Service Providers (DSPs). To avoid any potential shortfalls or co-payments for Prescribed Minimum Benefit conditions, you are required to utilize the DSPs associated with Momentum Medical Scheme. This is particularly important, except in emergency situations where you may not have a choice regarding the healthcare providers you can use. The DSPs are strategically selected to ensure that you have access to healthcare treatment at the most favorable industry rates available. If you choose to seek treatment from a healthcare provider that is not part of the DSP arrangement for services related to Prescribed Minimum Benefits, the Scheme may not cover the full costs. This holds true even if you are enrolled in an option that offers you the freedom to choose your provider. You may find yourself responsible for paying the difference or facing a higher co-payment when utilizing non-designated service providers. Additionally, it is imperative that you utilize the medicine formularies established by Momentum Medical Scheme for conditions classified as Prescribed Minimum Benefits. By doing so, you can avoid any shortfalls or co-payments associated with your medication. Detailed information regarding the formulary medicines applicable to your benefit option, as well as details concerning co-payments related to your chronic medication, can be found by logging into momentummedicalscheme.co.za. Lastly, it is your responsibility to ensure that all relevant and accurate information is shared with us. This includes submitting all necessary information when you seek pre-authorization, register for chronic benefits, and submit claims. We require the appropriate ICD-10 codes, tariffs, and any health-related information that will enable us to effectively review requests for registrations related to Prescribed Minimum Benefits.

Glossary of Terms Used in This Document

Chronic Disease List The Chronic Disease List refers to a compilation of 26 chronic conditions that all medical schemes in South Africa are mandated to provide coverage for, as stipulated by the Medical Schemes Act No 131 of 1998. This list is crucial for ensuring that individuals suffering from these long-term health issues receive the necessary medical attention and support without facing financial hardship.

Clinical Protocol Momentum Medical Scheme employs specific treatment guidelines known as clinical protocols. These protocols are designed to determine and manage the benefits available for various health conditions. By adhering to these established protocols, the scheme aims to provide consistent and effective treatment options for its members, ensuring that care is both appropriate and evidence-based.

Clinically Appropriate The term "clinically appropriate" refers to treatments that align with the clinical protocols outlined by the Momentum Medical Scheme for particular health conditions. This ensures that the care provided is not only suitable but also adheres to the best practices and standards recognized in the medical community.

Co-payment A co-payment is a specified amount that you, as a member, are required to contribute towards medical procedures and treatments. The exact amount of the co-payment can differ based on the type of procedure or treatment being administered, as well as the location where it is performed. In instances where the co-payment exceeds the total cost charged by the healthcare provider, you will be responsible for covering the additional expenses. It is important to note that co-payments do not apply in emergencies, but they may be required for non-emergency treatments that fall under the Prescribed Minimum Benefits.

Designated Service Providers Momentum Medical Scheme has established a network of Designated Service Providers for Prescribed Minimum Benefits, which vary based on the specific benefit option you have chosen. To avoid incurring co-payments when accessing these benefits, it is essential to utilize the Designated Service Providers with whom the scheme has negotiated rates and established payment arrangements. This network includes providers from the Ingwe Primary Care Network, various Associated Network General Practitioners (GPs), specialists, pharmacies, hospitals, and State facilities. In cases of emergency medical conditions, or if you are forced to use a non-designated service provider, these rules may not apply. For a comprehensive list of Designated Service Providers in your area, you can log into the Momentum App or visit momentummedicalscheme.co.za. Additionally, if a State facility is your designated provider, you have the option to use any State facility available to you.

Diagnostic Treatment Pairs Under the Medical Schemes Act, there exists a schedule of Diagnostic Treatment Pairs, which collectively form the Prescribed Minimum Benefits that must be provided to beneficiaries of medical schemes. This schedule includes a total of 271 Diagnostic Treatment Pairs, each linked to specific treatments that all medical schemes are obligated to fund. This framework ensures that members receive essential care for their diagnosed conditions.

Emergency Medical Condition An emergency medical condition is defined as the sudden and unexpected emergence of a health issue that necessitates immediate medical or surgical intervention. If such treatment is not provided promptly, it could lead to serious impairment of bodily functions, significant dysfunction of an organ or body part, or even place the individual’s life in grave danger. Recognizing and responding to these conditions swiftly is critical for preserving health and well-being.

Formulary A formulary is a curated list of medications that are covered under your specific benefit option. This list serves as a guide for healthcare providers, allowing them to prescribe the appropriate medications for managing your chronic condition. The formulary ensures that members have access to the necessary medications while also promoting the responsible use of healthcare resources.

Pre-authorisation Pre-authorisation is the process by which you inform the Momentum Medical Scheme before receiving medical treatment. By contacting the scheme, you can confirm whether your expected treatment is covered and understand the reimbursement rates applicable to your benefit option. Upon approval, you will receive a pre-authorisation number, which you must provide to your healthcare provider. While obtaining pre-authorisation does not guarantee coverage for the treatment, it offers reassurance that the benefits will be aligned with the Scheme Rules, your chosen option, and your membership status.

PMB Level of Care The PMB level of care is grounded in the principle of medical necessity. This means that the services and treatments provided must be appropriate and essential for diagnosing or treating a given condition, in accordance with accepted medical standards and guidelines. This principle is fundamental to ensuring that members receive the care they need when they need it.

Reference Price List (RPL) The Reference Price List (RPL) is a set of guidelines published by the Department of Health. This list serves as a pricing benchmark, aiding medical schemes in determining the tariffs or rates used when calculating reimbursements for healthcare services. By adhering to the RPL, medical schemes can ensure that their pricing is consistent and fair, ultimately benefiting their members.

Contact Us If you wish to register a condition that falls under the Prescribed Minimum Benefit (PMB) category or if you require additional information regarding Prescribed Minimum Benefits, we encourage you to reach out to us using the following methods:

For immediate assistance, you can contact our dedicated call center at 0860 1 1 78 59. Our trained representatives are available to provide you with the support you need. Alternatively, you can also reach us via WhatsApp at the same number, 0860 1 1 78 59, allowing you to communicate with us conveniently from your mobile device.

For those who prefer online communication, we offer a web chat service. Simply log in to our website at momentummedicalscheme.co.za and click on the chat button to initiate a conversation with one of our knowledgeable consultants. This service is designed to provide you with real-time assistance for any inquiries you may have.

Additionally, we provide virtual help sessions that you can access by visiting momentummedicalscheme.co.za. Click on the "Contact Us" section, and then select "Click here to join a virtual help session." This will connect you with one of our consultants who can assist you directly in a virtual setting.

If you prefer to communicate via email, you can send your inquiries to [e-mail]. When sending an email, please ensure that you include your membership number so we can assist you more efficiently.

Should you need further clarification regarding your claims related to Prescribed Minimum Benefits, or if you suspect that your claims have not been processed or paid correctly under the PMB guidelines, we urge you to email us at [e-mail]. Our team is here to help you resolve any issues and ensure that you receive the benefits you are entitled to.