- 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).
Schemes have to cover at least the prescribed PMB level of care for these conditions, without requiring co-payments or savings from you, even if the treatment is provided out-of-hospital. This applies to every plan.
Medical Aid Schemes obligations re PMBs
By law, the medical scheme have to cover the diagnosis, treatment and management of 270 pre-defined conditions, including most cancers. As a scheme member, you will not be required to make co-payments or use your savings for this treatment, even if it is done out-of-hospital.
Nevertheless, this is not free-for-all-ride.
There are important caveats of which you need to be aware.
DSPs are Designated Service Providers. You will see this acronym often. DSPs are providers chosen by some schemes to provide the healthcare services for PMBs.
If you choose to use providers other than the DSPs, the scheme can require you to pay the difference between what your provider chargers and what the DSP would have charged.
It is perfectly legal for schemes to assign state facilities as DSPs, and many do. That means that, while you are a member of those plans, you will be required to (most likely) receive PMB treatment from a state facility, even though you are a member of a private medical aid scheme.
PMB protocol and PMB level of care
The government has identified and listed “treatment pairs” for all 270 PMB conditions, which outline the level of care a PMB patient needs to have funded by a scheme. For example,
|906A||Acute generalised paralysis, including polio and Guillain-Barre||Medical management; ventilation and plasmapheresis|
|341A||Basal ganglia, extra-pyramidal disorders; other dystonias||NOS Initial diagnosis; initiation of medical management|
|950A||Benign and malignant brain tumours, treatable||Medical and surgical management which includes radiation therapy and chemotherapy|
So what does “Medical management” mean? The government has defined it as follows:
“Where the treatment component of a category .. is stated in general terms (i.e.”medical management” or “surgical management”) it should be interpreted as referring to prevailing hospital-based medical or surgical diagnostic and treatment practice for the specified condition. Where significant differences exist between Public and Private sector practices, the interpretation of the Prescribed Minimum Benefits should follow the predominant Public Hospital practice,….”
In other words, the level of care that you need to receive is, in most instances, at minimum the level of care that you would receive if you were a patient of the state, in public facilities. However, in most cases you will receive these services from private facilities, unless your plan specifies “state facilities” only. Note that this is the minimum level of care, as required by law. Many schmes/plans offer superior healthcare coverage to the minimum that is required.
PMBs and cancer
Most cancers are considered PMBs, and therefore you are funded for out-of-hospital treatment for cancer under the PMB legislation, even if you are on a hospital-only plan.
However, there are some limitations. For starters, only treatable cancers are considered PMBs. Once again, according to the government notes:
In general, solid organ malignant tumours (excluding lymphomas) will be regarded as treatable where:
i) they involve only the organ of origin, and have not spread to adjacent organs
ii) there is no evidence of distant metastatic spread
iii) they have not, by means of compression, infarction, or other means, brought about irreversible and irreparable damage to the organ within which they originated (for example brain stem compression caused by a cerebral tumour) or another vital organ
iv) or, if points i. to iii. do not apply, there is a well demonstrated five year survival rate of greater than 10% for the given therapy for the condition concerned
If your scheme covers cancer as a PMB and your cancer does not meet the above criteria, it will not be covered.
In addition, there are specific criteria for tumor chemotherapy:
Tumour chemotherapy with or without bone marrow transplantation and other indications for bone marrow transplantation. These are included in the prescribed minimum benefits package only where Annexure A explicitly mentions such interventions. Management may include a first full course of chemotherapy (including, if indicated, induction, consolidation and myeloablative components). Where specified in terms of Annexure A, this may be followed by bone marrow transplantation/rescue, according to tumour type and prevailing practice. The following conditions would also apply to the bone marrow transplantation component of the prescribed minimum benefits:
i) the patient should be under 60 years of age
ii) allogeneic bone marrow transplantation should only be considered where there is an HLA matched family donor
iii) the patient should not have relapsed after a previous full course of chemotherapy
iv) (points i. and ii. shall also apply to bone marrow transplantation for non-malignant diseases)
(Note: “Annexure A” is this list“)
The prescribed minimum benefits include solid organ transplants (liver, kidney and heart) only where these are provided by Public hospitals in accordance with Public sector protocols and subject to public sector waiting lists.
Hospital treatment where the diagnosis is uncertain and/or admission for diagnostic purposes. Urgent admission may be required where a diagnosis has not yet been made. Certain categories of prescribed minimum benefits are described in terms of presenting symptoms, rather than diagnosis, and in these cases, inclusion within the prescribed minimum benefits may be assumed without a definitive diagnosis. In other cases, clinical evidence should be regarded as sufficient where this suggests the existence of a diagnosis that is included within the package.
Medical schemes may, however, require confirmatory evidence of this diagnosis within a reasonable period of time, and where they consistently encounter difficulties with particular providers or provider networks, such problems should be brought to the attention of the Council for Medical Schemes for resolution.
List of the 270 PMB conditions (defined in the Diagnosis Treatment Pairs)