• 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

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.

Throughout the year, we are going to add the DSP lists or criteria for each scheme. You can also use our forums to log your experience and read about other people’s experiences.

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,

You can see the full list here.

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.

Chemotherapy

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“)

Organ transplants

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.

Diagnosis

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.

Also see:
List of the 270 PMB conditions (defined in the Diagnosis Treatment Pairs)

The post All about PMBs, and how schemes have to pay for them appeared first on Medical Aid Bible.

IMPORTANT: For an explanation of general treatments (example: “Medical Management”) please click here

NOS means “not otherwise specified”.

BRAIN AND NERVOUS SYSTEM

EYE

EAR, NOSE, MOUTH AND THROAT

RESPIRATORY

HEART AND VASCULATURE

GASTRO-INTESTINAL SYSTEM

LIVER, PANCREAS AND SPLEEN

MUSCULOSKELETAL SYSTEM; TRAUMA NOS

SKIN AND BREAST

ENDOCRINE, METABOLIC AND NUTRITIONAL

URINARY AND MALE GENITAL SYSTEM

FEMALE REPRODUCTIVE SYSTEM

PREGNANCY AND CHILDBIRTH

HAEMATOLOGICAL, INFECTIOUS AND MISC SYSTEMIC CONDITIONS

MENTAL ILLNESS

Chronic PMB conditions

Addison’s Disease
Asthma
Bipolar Mood Disorder
Bronchiectasis
Cardiac Failure
Cardiomyopathy
Chronic Renal Disease
Chronic Obstructive Pulmonary Disease
Coronary Artery Disease
Crohn’s Disease
Diabetes Insipidus
Diabetes Mellitus Types 1 & 2
Dysrhythmias
Epilepsy
Glaucoma
Haemophilia
Hyperlipidaemia
Hypertension
Hypothyroidism
Multiple Sclerosis
Parkinson’s Disease
Rheumatoid Arthritis
Schizophrenia
Systemic Lupus Erythematosus
Ulcerative Colitis

The post List of PMB conditions and their prescribed treatment appeared first on Medical Aid Bible.

Choosing the best medical aid for your needs is one of the most important decisions you need to take. The choice affects not only the level of your healthcare, but also has huge financial implications for you and your family.

Choosing the correct plan is a fine balance between your healthcare needs, your affordability and your risk aversion level. Since all three of these inputs are so personal to your individual situation, we cannot recommend a blanket “best” plan.

Although we have tried to simplify information as much a we can, we have not been able to avoid some of the necessary jargon, and we do not have full insight into how the schemes operate.

Forums

To add to the transparency, we have introduced Forums to the website, and we encourage you to participate. By offering you a forum for your own experience with a healthcare funding issue, and the specific scheme, we hope to add even more transparency to the healthcare system, as well as more accountability. We encourage you to participate and read the forums. You can find out more here.

Scheme Rate

This is the foundation block of how schemes pay for claims. Every healthcare “line item” has an IDC code, and each scheme sets the maximum price it will pay for that code. If your healthcare provider charges more than this scheme rate, you will have to pay the difference out of pocket.

There are two main exceptions to this:

• Some schemes pay at “200% scheme rate” or “300% scheme rate” on some plans. That means they those plans will pay a multiple of their basic scheme rate to the healthcare provider, thus minimising your out-of-pocket expenses.
• Some schemes guarantee that they will cover the healthcare cots of provider if the providers are part of the scheme’s network, or if the providers have a payment arrangement with the scheme. The actual rate the provider then charges is irrelevant to you

Lastly, if your plan offers an above threshold benefit, it is very likely that claims accumulate to the threshold at 100% scheme tariff only, regardless of the actual cost claimed.

PMBs

The medical aid sector is governed by the Medical Aid Schemes Act, and that Act directs medical aid schemes to pay for the diagnosis and treatment of 270 conditions according to certain guidelines, and without charging you the end user directly for the treatment.

In other words, when you get treated for any of the 270 conditions, the schemes have to cover your costs without asking you for a co-payment, and without using your medical aid savings.

These 270 conditions, known a Prescribed Minimum Benefits (PMBs) cause much problems and confusion, for schemes, healthcare providers and for you.

We are committed to using this website to offer as much transparency to PMBs as possible, while also pointing out their pitfalls. You can find a list of the PMBs here, a collection of all our PMB content here,and more general info on PMBs here.

Update: The government has indicated that it will re-look at the PMB legislation, and will implement changes as soon as March 2017.

Here is what you need to know now, applicable for now:

• The 270 conditions cover all life threatening conditions, as well as most cancers and other degenerative conditions.
• As a medical aid member, you are guaranteed in hospital and out of hospital treatment for these conditions.
• Only “treatable” cancers are considered PMBs. Read more here.
• Schemes can prescribe where you receive treatment for PMBs, and most have Designated Service Providers (DSPs) to offer this service. If you choose to not use a DSP for a PMB, you might be liable for extra costs, as schemes are not obligated to covers costs above those charged by the DSP. This is a very important caveat, since a lot of schemes/plan designate state hospitals as DSPs. Therefore, you might think you have coverage for private hospitals, but in fact if you are treated for a PMB you might be relegated to a state hospital, or have to co-pay for a private hospital treatment. You can read more about DSPs here.
• The Act pairs each PMB with the minimum treatment that must be covered by the scheme. Unfortunately, in most cases, this treatment is simply described under a blanket description of “Managed care”. In very simple terms, what this mostly means is that the scheme has to pay for the treatment that a public hospital would offer to a non-scheme member who suffered from the same condition.
  It is reasonable to assume that as a scheme paying member, you might want better, more advanced treatment. Be aware that this might cost you out-of-pocket. For more specific information on this, read about the obligations medical aid schemes have re PMBs.
• The good news is that you have to be offered treatment, including out-of-hospital treatment, for all PMB conditions, no matter what plan you are on. That means that if you are financially constrained, you can rest easy knowing that even the cheapest plans guarantee coverage and out-of-hospital treatment for many conditions that would otherwise be affordable to you.
• The bad news is that PMB coverage requires careful ongoing management from you the scheme member. You have to be very vigilant that you are getting the coverage that is due to you, that you are not co-paying, and that you are using the DSPs. There is more information on this on our website under each scheme, and you can also read all our PMB content here.

Types of plans

Hospital plans: these cover in-hospital costs only, as well as out-of-hospital costs for any approved PMB conditions (see above). Some schemes may offer some extra benefits like preventative care, standard dentistry etc.

Savings: some plans set aside a portion of your premium toward out-of-hospital or day-to-day costs. You usually get the full years value of the extra premiums available in January. Savings cannot be used by scheme to fund PMB benefits prescribed by law.

“Extended Funds”: Different schemes have different names for these, but essentially it is a “budget” that schemes allocate to you for day-to-day expenses.

Comprehensive plans: These plans usually offer a savings account (see above), and once that is depleted might force you to pay for out-of-hospital expenses out of pocket (self payment gap). However, after a while, when all the day-to-day claims that have been paid (either by scheme or by you) accumulate to a certain amount, the scheme starts paying all further claims once again. This is called “above threshold benefit”. Some plans limit this benefit, and some plans have it as unlimited, with sub-limits for various benefits. See more here.

Income based plans: Some plans are income based plans, which means that the premiums you pay as a member are adjusted on a sliding scale according to your income. The less you make, the less you pay. Schemes define “income” according to own rules, so check with the scheme.

Managed care

All schemes have managed care programs, which you need to join if you want to get the full benefits available for certain conditions. By joining such a program, you will most likely be assigned a case manager to help you manage your condition, get you the care that you need and ease the claim process.

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